Individual
MARK ALAN SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
3322 W WILLOW KNOLLS DR, PEORIA, IL 61614
(309) 691-5800
(309) 691-1336
Mailing address
3322 W WILLOW KNOLLS DR, PEORIA, IL 61614
(309) 691-5800
(309) 691-1336
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
Primary
016004790
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0007215174
BLUE CROSS BLUE SHIELD
IL
05
—
016004790
—
IL
01
—
480022534
RAILROAD MEDICARE
IL
01
—
928270
MEDICARE PROVIDER
IL
Enumeration date
11/08/2006
Last updated
12/03/2009
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