Provider Demographics
NPI:1003162058
Name:STACY R SMITH MD PC
Entity Type:Organization
Organization Name:STACY R SMITH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-424-3090
Mailing Address - Street 1:1548 E 4500 S
Mailing Address - Street 2:STE 105
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4209
Mailing Address - Country:US
Mailing Address - Phone:801-424-3090
Mailing Address - Fax:801-424-3091
Practice Address - Street 1:1548 E 4500 S
Practice Address - Street 2:STE 105
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4209
Practice Address - Country:US
Practice Address - Phone:801-424-3090
Practice Address - Fax:801-424-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT60248791205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty