Healthcare Provider Details

I. General information

NPI: 1841358223
Provider Name (Legal Business Name): WESLEY LINCOLN SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E VAN BUREN ST
PHOENIX AZ
85008-6037
US

IV. Provider business mailing address

2500 E VAN BUREN ST
PHOENIX AZ
85008-6037
US

V. Phone/Fax

Practice location:
  • Phone: 480-695-6625
  • Fax:
Mailing address:
  • Phone: 480-695-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2616
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number2616
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2616
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: