Basic Information
| Provider Information | |||||||||
| NPI: | 1902975105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3165 MCCRORY PL | ||||||||
| Address2: | STE 174 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328033727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074231234 | ||||||||
| FaxNumber: | 4075171040 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 GLENWOOD DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076471550 | ||||||||
| FaxNumber: | 4076471561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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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 | 213ES0103X | PO2033 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 59-2580012 | 01 | FL | TAX ID | OTHER | 340400500 | 05 | FL | MEDICAID |