Provider Demographics
NPI:1063974814
Name:SMOCK, REBECCA IRENE (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:IRENE
Last Name:SMOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 E STATE ROAD 44
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-9199
Mailing Address - Country:US
Mailing Address - Phone:317-736-8474
Mailing Address - Fax:317-736-6040
Practice Address - Street 1:990 E STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9199
Practice Address - Country:US
Practice Address - Phone:317-736-8474
Practice Address - Fax:317-736-6040
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11020421A390200000X
IN02006297A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program