Healthcare Provider Details

I. General information

NPI: 1619926250
Provider Name (Legal Business Name): BRIAN L SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 LUSK DR
NEOSHO MO
64850
US

IV. Provider business mailing address

2550 LUSK DR
NEOSHO MO
64850-8855
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-2060
  • Fax: 417-451-6214
Mailing address:
  • Phone: 417-451-2060
  • Fax: 417-451-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2001008549
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: