Provider Demographics
NPI:1174873277
Name:SMITH, CHARLES MITTNACHT (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MITTNACHT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PADRE KINO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2900
Mailing Address - Country:US
Mailing Address - Phone:505-992-1101
Mailing Address - Fax:505-992-1101
Practice Address - Street 1:1101 PADRE KINO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2900
Practice Address - Country:US
Practice Address - Phone:505-992-1101
Practice Address - Fax:505-992-1101
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-16
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0000685207K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology