Provider Demographics
NPI:1104988518
Name:SMITH, TROY DALE (DC)
Entity type:Individual
Prefix:DR
First Name:TROY
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:VEVAY
Mailing Address - State:IN
Mailing Address - Zip Code:47043-1223
Mailing Address - Country:US
Mailing Address - Phone:812-525-6546
Mailing Address - Fax:
Practice Address - Street 1:315 FERRY ST
Practice Address - Street 2:STE A
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-1189
Practice Address - Country:US
Practice Address - Phone:812-438-9222
Practice Address - Fax:812-438-9222
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001849A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200226260BMedicaid
INP00045015OtherMEDICARE RAILROAD
IN000000298895OtherBLUE CROSS BLUE SHEILD
IN209520Medicare ID - Type Unspecified