Provider Demographics
NPI:1043283856
Name:SMITH, STANTON MILLER (DPM)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:MILLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 E 5900 S # 102
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7287
Mailing Address - Country:US
Mailing Address - Phone:801-441-2719
Mailing Address - Fax:801-327-2304
Practice Address - Street 1:168 E 5900 S # 102
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7287
Practice Address - Country:US
Practice Address - Phone:801-441-2719
Practice Address - Fax:801-327-2304
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1045170501213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870417150OtherTAX ID NUMBER
UT870417150OtherTAX ID NUMBER
UT0910680001Medicare NSC