Healthcare Provider Details

I. General information

NPI: 1487971560
Provider Name (Legal Business Name): KODY JE SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 E OSBORN RD
SCOTTSDALE AZ
85256-4019
US

IV. Provider business mailing address

1489 S HIGLEY RD STE 101
GILBERT AZ
85296-4777
US

V. Phone/Fax

Practice location:
  • Phone: 480-362-7400
  • Fax: 480-362-5950
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: