Healthcare Provider Details

I. General information

NPI: 1003802968
Provider Name (Legal Business Name): STANLEY R SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 05/02/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17310 WRIGHT ST STE 103
OMAHA NE
68130-2405
US

IV. Provider business mailing address

17310 WRIGHT ST STE 103
OMAHA NE
68130-2405
US

V. Phone/Fax

Practice location:
  • Phone: 833-228-6889
  • Fax: 877-853-0376
Mailing address:
  • Phone: 833-228-6889
  • Fax: 877-853-0376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number34173
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2018011357
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number11738C
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMTL-2023-030
License Number StateGU
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16510
License Number StateND
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-2422
License Number StateGU
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34173
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: