Provider Demographics
NPI:1134101843
Name:SMITH, DANIEL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
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 1:7219 N LITCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LUKE AFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85309-1529
Mailing Address - Country:US
Mailing Address - Phone:623-856-7975
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:LUKE AFB
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50799207P00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060807Medicaid