MEDICARE: DEAN TY SMITH D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	O-136	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144252099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEAN TY SMITH D.O.

Provider Business Mailing Address
First Line	:	500 S 11TH AVE STE 400
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-4880
Country	:	US
Telephone Number	:	208-232-7862
Fax Number	:	208-232-7869

Provider Business Practice Location Address
First Line	:	79 N MAIN ST
Second Line	:
City	:	DOWNEY
State	:	ID
Zip	:	83234-4703
Country	:	US
Telephone Number	:	208-897-5600
Fax Number	:	208-897-5603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	03/06/2024

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Directions to “ DEAN TY SMITH D.O.” Practice Location

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