Healthcare Provider Details

I. General information

NPI: 1700830601
Provider Name (Legal Business Name): LEROY CARTER SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 SILVER CREEK RD SUITE 111
BULLHEAD CITY AZ
86442-7904
US

IV. Provider business mailing address

2755 SILVER CREEK RD SUITE 111
BULLHEAD CITY AZ
86442-7904
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-7163
  • Fax: 928-704-7140
Mailing address:
  • Phone: 928-704-7163
  • Fax: 928-704-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number26371
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number26371
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number41584
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: