Healthcare Provider Details

I. General information

NPI: 1801843230
Provider Name (Legal Business Name): LAURA DIANE SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 1ST CAPITOL DR
SAINT CHARLES MO
63301-2844
US

IV. Provider business mailing address

300 1ST CAPITOL DR
SAINT CHARLES MO
63301-2844
US

V. Phone/Fax

Practice location:
  • Phone: 636-947-5662
  • Fax: 636-947-5250
Mailing address:
  • Phone: 636-947-5662
  • Fax: 636-947-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2000158417
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: