Provider Demographics
NPI:1003803925
Name:SMITH, GREGG ALAN (DO)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GREGG
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO, PC
Mailing Address - Street 1:3928 E MINTON CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1727
Mailing Address - Country:US
Mailing Address - Phone:480-242-6297
Mailing Address - Fax:
Practice Address - Street 1:1042 N HIGLEY RD
Practice Address - Street 2:SUITE 102-602
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5398
Practice Address - Country:US
Practice Address - Phone:480-242-6297
Practice Address - Fax:480-699-3129
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2813208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619184652OtherNPI
AZ318198OtherAHCCCS
Z72611Medicare PIN
F66758Medicare UPIN
72611Medicare ID - Type Unspecified