Provider Demographics
NPI:1215977566
Name:SMITH, JOHN D (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
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 1:609 E CENTRE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002
Mailing Address - Country:US
Mailing Address - Phone:269-329-1660
Mailing Address - Fax:269-329-0821
Practice Address - Street 1:609 E CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-5514
Practice Address - Country:US
Practice Address - Phone:269-329-1660
Practice Address - Fax:269-329-0821
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI382719395111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT32948Medicare UPIN
MI0C95007Medicare ID - Type Unspecified