Basic Information
| Provider Information | |||||||||
| NPI: | 1790762870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1331 MINNICH RD | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467742051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739600 | ||||||||
| FaxNumber: | 2603739602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01027868A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100053750 | 05 | IN | MEDICAID | 00001291560 01 | 01 | UNITED HEALTHCARE | OTHER | 080130028 | 01 | IN | RAILROAD MEDICARE | OTHER | 4047064 | 01 | AETNA | OTHER | 000000111933 | 01 | IN | ANTHEM | OTHER | 1867 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER |