Healthcare Provider Details

I. General information

NPI: 1174873277
Provider Name (Legal Business Name): CHARLES MITTNACHT SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2012
Last Update Date: 09/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 PADRE KINO
SANTA FE NM
87501-2900
US

IV. Provider business mailing address

1101 PADRE KINO
SANTA FE NM
87501-2900
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-1101
  • Fax: 505-992-1101
Mailing address:
  • Phone: 505-992-1101
  • Fax: 505-992-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberC1-0000685
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0000685
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: