Provider Demographics
NPI:1043204746
Name:SMITH, SCOTT ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3067 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-1273
Mailing Address - Country:US
Mailing Address - Phone:208-522-4600
Mailing Address - Fax:208-552-7521
Practice Address - Street 1:3067 EAGLE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-1273
Practice Address - Country:US
Practice Address - Phone:208-522-4600
Practice Address - Fax:208-552-7521
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-257208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010032253OtherBLUE SHIELD
ID42283OtherBLUE CROSS
ID806039800Medicaid