MEDICARE: DR. LISA REGALADO SMITH PH.D.

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	207SC0300X	Clinical Cytogenetics Physician	2005157	NM

General Provider Information

NPI Number	:	1841563061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA REGALADO SMITH PH.D.

Provider Business Mailing Address
First Line	:	1351 SAN ILDEFONSO RD
Second Line	:
City	:	LOS ALAMOS
State	:	NM
Zip	:	87544-2873
Country	:	US
Telephone Number	:	734-223-9955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1351 SAN ILDEFONSO RD
Second Line	:
City	:	LOS ALAMOS
State	:	NM
Zip	:	87544-2873
Country	:	US
Telephone Number	:	734-223-9955
Fax Number	:

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

Provider Enumeration Date	:	02/18/2012
Last Update Date	:	02/18/2012

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