Provider Demographics
NPI:1699779538
Name:SMITH, DANIEL BURTION (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BURTION
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1200 N STATE HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1224
Mailing Address - Country:US
Mailing Address - Phone:217-864-5531
Mailing Address - Fax:217-864-2449
Practice Address - Street 1:4965 E LOST BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5139
Practice Address - Country:US
Practice Address - Phone:217-864-5531
Practice Address - Fax:217-864-2449
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2021-12-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036070695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360706951Medicaid
IL0360706951Medicaid
IL742600Medicare ID - Type Unspecified