Basic Information
| Provider Information | |||||||||
| NPI: | 1245290543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7974 UW HEALTH CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625531 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N NINE MOUNDS ROAD | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088459531 | ||||||||
| FaxNumber: | 6088455954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 12/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23250 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.