Basic Information
| Provider Information | |||||||||
| NPI: | 1699739672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DRIVE | ||||||||
| Address2: | MAILBOX 117 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 E MAUMEE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467032035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606672600 | ||||||||
| FaxNumber: | 2606657312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01051461 | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000672898 | 01 | IN | ANTHEM | OTHER | 01051461 | 01 | IN | STATE LICENSE | OTHER | 200248720A | 05 | IN | MEDICAID |