Healthcare Provider Details

I. General information

NPI: 1275559262
Provider Name (Legal Business Name): CLARENCE MILTON SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 2ND AVE SW
MINOT ND
58701-3459
US

IV. Provider business mailing address

900 E BROADWAY AVE PO BOX 997
BISMARCK ND
58502-0997
US

V. Phone/Fax

Practice location:
  • Phone: 701-858-1800
  • Fax: 701-530-8842
Mailing address:
  • Phone: 701-530-8833
  • Fax: 701-530-8842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3205
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: