Provider Demographics
NPI:1316995525
Name:SMITH, MARK DAVID (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6479
Mailing Address - Country:US
Mailing Address - Phone:715-855-0408
Mailing Address - Fax:715-855-0409
Practice Address - Street 1:2600 S WISCONSIN AVE STE A
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-7527
Practice Address - Country:US
Practice Address - Phone:715-855-0430
Practice Address - Fax:715-236-3615
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6121024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40312100Medicaid
WIP00219426Medicare UPIN
WI40312100Medicaid