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General NPI Number Information
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NPI Number | 1710904636
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Entity Type | Organization
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Legal Business Name | SAM P SMITH DO LLC
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Dates
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Enumeration Date | 07/16/2006
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 4915 E BASELINE RD SUITE 102
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City | GILBERT
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State | AZ
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Zip | 85234-2965
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Country | US
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Telephone | 480-646-8660
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Fax | 480-646-8665
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Provider Business Mailing Address
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Address Line | 4915 E BASELINE RD SUITE 102
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City | GILBERT
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State | AZ
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Zip | 85234-2965
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Country | US
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Telephone | 480-646-8660
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Fax | 480-646-8665
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SAM P SMITH
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Credential | D.O.
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Telephone | 602-369-6845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 4237
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License Number State | AZ
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