Provider Demographics
NPI:1083731103
Name:SMITH, BARRY A (DO)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:A
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 1:307 SAINT JOHNS WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2435
Mailing Address - Country:US
Mailing Address - Phone:208-743-7612
Mailing Address - Fax:208-746-4802
Practice Address - Street 1:307 SAINT JOHNS WAY STE 4
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2435
Practice Address - Country:US
Practice Address - Phone:208-743-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013507208600000X
IDO-0654208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery