Provider Demographics
NPI:1154349900
Name:SMITH-CHASE, LATISHA A (MD)
Entity type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:A
Last Name:SMITH-CHASE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATISHA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-563-4466
Mailing Address - Fax:
Practice Address - Street 1:400 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9567
Practice Address - Country:US
Practice Address - Phone:920-699-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57131207R00000X, 2083P0011X
WI73794-202083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE68863Medicare UPIN
TX83680JOtherBCBS
TXE68863Medicare UPIN
TX83680JMedicare PIN
TX103671702Medicaid