Provider Demographics
NPI:1306854567
Name:SMITH, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SMITH
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 4216
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17604-4216
Mailing Address - Country:US
Mailing Address - Phone:717-394-6028
Mailing Address - Fax:717-394-9223
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5941
Practice Address - Fax:717-544-5907
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY256562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64256563Medicaid
KY50009541Medicaid
KY000000388816OtherANTHEM BLUE FACET
IN200814750Medicaid
PA104362717Medicaid
KY1279226Medicare ID - Type Unspecified
KY64256563Medicaid