Healthcare Provider Details

I. General information

NPI: 1124199476
Provider Name (Legal Business Name): MICHAEL B SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-1022
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-1022
US

V. Phone/Fax

Practice location:
  • Phone: 409-747-0890
  • Fax: 409-772-0885
Mailing address:
  • Phone: 409-747-0890
  • Fax: 409-772-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberG8977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: