Healthcare Provider Details

I. General information

NPI: 1265409643
Provider Name (Legal Business Name): SANDRA LYNN SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 S SAN FRANCISCO ST BLDG. #25 NAU
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

PO BOX 6033
FLAGSTAFF AZ
86011-0181
US

V. Phone/Fax

Practice location:
  • Phone: 928-523-2131
  • Fax: 928-523-1102
Mailing address:
  • Phone: 928-523-2131
  • Fax: 928-523-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24852
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: