=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154452795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA CLETUS SMITH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 S BRENTWOOD BLVD STE 100
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63144-1320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-918-8827
-----------------------------------------------------
Fax | 314-918-9391
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7412065
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-2065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-918-8827
-----------------------------------------------------
Fax | 314-918-9391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2007006308
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------