Provider Demographics
NPI:1265547145
Name:SMITH, WILLIAM DAVID (DC, PT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8906
Mailing Address - Country:US
Mailing Address - Phone:815-793-1274
Mailing Address - Fax:
Practice Address - Street 1:445 ALDEN DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8906
Practice Address - Country:US
Practice Address - Phone:815-793-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009548225100000X
IL038006978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU17478Medicare UPIN
ILK26248Medicare ID - Type Unspecified