Healthcare Provider Details

I. General information

NPI: 1417211756
Provider Name (Legal Business Name): NIKOL LEI SMART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKOL LEI MCDONALD MD

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY STE 206
O FALLON MO
63368-2206
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR STE. 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-1073
  • Fax: 636-344-1075
Mailing address:
  • Phone: 636-344-1073
  • Fax: 636-344-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2016016729
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: