Basic Information
| Provider Information | |||||||||
| NPI: | 1861498669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S CODY RD | ||||||||
| Address2: | |||||||||
| City: | LE CLAIRE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527539579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632893008 | ||||||||
| FaxNumber: | 5632893024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02372 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 46888 | 01 | WELLMARK HEALTH PLANS | OTHER | 049407 | 01 | HEALTH ALLIANCE | OTHER | 1071621 | 05 | IA | MEDICAID | IA01C1 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 19839 | 01 | IOWA HEALTH SOLUTIONS | OTHER | 4796890012 | 01 | DMERC | OTHER |