Healthcare Provider Details

I. General information

NPI: 1609211291
Provider Name (Legal Business Name): CLARISA I. SMITH, MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N MAIN ST SUITE 1C
PRESCOTT VALLEY AZ
86314-1216
US

IV. Provider business mailing address

111 CHESTER AVE
ANNAPOLIS MD
21403-3311
US

V. Phone/Fax

Practice location:
  • Phone: 928-458-5470
  • Fax: 928-458-5979
Mailing address:
  • Phone: 602-431-1152
  • Fax: 602-431-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35537
License Number StateAZ

VIII. Authorized Official

Name: KIRSTEN A SORENSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-431-1152