Healthcare Provider Details

I. General information

NPI: 1003803925
Provider Name (Legal Business Name): GREGG ALAN SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GREGG SMITH D.O., PC

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 N HIGLEY RD SUITE 102-602
MESA AZ
85205-5398
US

IV. Provider business mailing address

3928 E MINTON CIR
MESA AZ
85215-1727
US

V. Phone/Fax

Practice location:
  • Phone: 480-242-6297
  • Fax: 480-699-3129
Mailing address:
  • Phone: 480-242-6297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2813
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2813
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: