Healthcare Provider Details

I. General information

NPI: 1881629202
Provider Name (Legal Business Name): CRAIG M SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 N DISCOVERY PLACE
BOISE ID
83713-1556
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-5095
  • Fax: 208-367-5099
Mailing address:
  • Phone: 208-367-5095
  • Fax: 208-367-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM-12444
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4025
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: