Healthcare Provider Details

I. General information

NPI: 1538459672
Provider Name (Legal Business Name): THERESA CHRISTINE SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

460 SAINT MICHAELS DR SUITE 903
SANTA FE NM
87505-7619
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-5202
  • Fax:
Mailing address:
  • Phone: 505-986-8620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2014-0851
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: