Provider Demographics
NPI:1063632149
Name:SMITH, STEPHEN TROY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TROY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12361 W BOLA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:602-641-9486
Mailing Address - Fax:480-500-8430
Practice Address - Street 1:12361 W BOLA DR STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:602-641-9486
Practice Address - Fax:480-500-8430
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM13562086S0129X
AZ426042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ485155Medicaid
Z144227Medicare PIN