Provider Demographics
NPI:1124133087
Name:SMOLIK, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMOLIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-247-3266
Mailing Address - Fax:515-643-8688
Practice Address - Street 1:411 LAUREL ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3017
Practice Address - Country:US
Practice Address - Phone:515-247-3266
Practice Address - Fax:515-643-8688
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28916208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6120089Medicaid
IAF95889Medicare UPIN
IA55083Medicare ID - Type Unspecified