MEDICARE: MR. DOMINIQUE SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	211D00000X	Podiatric Assistant	NHA346213	TX

General Provider Information

NPI Number	:	1598534588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOMINIQUE SMITH

Provider Business Mailing Address
First Line	:	9511 PERRIN BEITEL RD APT 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-3538
Country	:	US
Telephone Number	:	713-393-9739
Fax Number	:

Provider Business Practice Location Address
First Line	:	9511 PERRIN BEITEL RD APT 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-3538
Country	:	US
Telephone Number	:	713-393-9739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/01/2024
Last Update Date	:	01/01/2024

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Directions to “ MR. DOMINIQUE SMITH ” Practice Location

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