Healthcare Provider Details

I. General information

NPI: 1427189422
Provider Name (Legal Business Name): BONNIE LEE SMOAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAMC-AFRIMS
APO AP
96546
US

IV. Provider business mailing address

USAMC-AFRIMS
APO AP
96546
US

V. Phone/Fax

Practice location:
  • Phone: 662-644-6691
  • Fax: 662-354-7873
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberD0035887
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: