Provider Demographics
NPI:1396304820
Name:SMITH, CHAD A (DPM)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-713-1779
Mailing Address - Fax:513-854-9921
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5412
Practice Address - Country:US
Practice Address - Phone:505-724-4384
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.004088213E00000X, 213ES0103X
NMPOD2024-0004213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19053223Medicaid
OH0019202Medicaid