Provider Demographics
NPI:1437173424
Name:SMITH, MILTON R (PA)
Entity type:Individual
Prefix:
First Name:MILTON
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-0170
Mailing Address - Country:US
Mailing Address - Phone:605-882-2630
Mailing Address - Fax:605-882-0447
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-2630
Practice Address - Fax:605-882-0447
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0402363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826413Medicaid
MN523390900Medicaid
SD4995950OtherBCBS
SDP00032136Medicare ID - Type UnspecifiedRAILROAD
MN970001742Medicare ID - Type Unspecified
SD6826413Medicaid
MN523390900Medicaid
R93594Medicare UPIN