Healthcare Provider Details

I. General information

NPI: 1205918646
Provider Name (Legal Business Name): JEFF D. SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56-565 KAMEHAMEHA HWY
KAHUKU HI
96731-2202
US

IV. Provider business mailing address

56-565 KAMEHAMEHA HWY
KAHUKU HI
96731-2202
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-3900
  • Fax:
Mailing address:
  • Phone: 808-432-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM4950
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-17452
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: