Healthcare Provider Details

I. General information

NPI: 1669559209
Provider Name (Legal Business Name): TERRY GLEN SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67-1123 MAMALAHOA HWY SUITE 120
KAMUELA HI
96743-8451
US

IV. Provider business mailing address

PO BOX 2650
KAMUELA HI
96743-2650
US

V. Phone/Fax

Practice location:
  • Phone: 808-885-5236
  • Fax: 808-885-4126
Mailing address:
  • Phone: 808-885-5236
  • Fax: 808-885-4126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6367
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number6367
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: