Healthcare Provider Details

I. General information

NPI: 1518285725
Provider Name (Legal Business Name): DOUGLAS SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 FAIRVIEW AVE N STE 100
ROSEVILLE MN
55113-1306
US

IV. Provider business mailing address

2720 FAIRVIEW AVE N STE 100
ROSEVILLE MN
55113-1306
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-5290
  • Fax: 651-241-5140
Mailing address:
  • Phone: 651-241-5290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberMT202293
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number60589
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: