Provider Demographics
NPI:1962405993
Name:SMITH, DAVID ALLEN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
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 1:7613 W JEFFERSON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4182
Mailing Address - Country:US
Mailing Address - Phone:260-469-7337
Mailing Address - Fax:260-469-7340
Practice Address - Street 1:7613 W JEFFERSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4182
Practice Address - Country:US
Practice Address - Phone:260-469-7337
Practice Address - Fax:260-469-7340
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040403A208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080877Medicaid
MI104683309Medicaid
IN200049180Medicaid
INF33234Medicare UPIN
IN200049180Medicaid