Provider Demographics
NPI:1144243767
Name:SMITH, BRAD D (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:D
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 1:2805 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7597
Mailing Address - Country:US
Mailing Address - Phone:208-542-2787
Mailing Address - Fax:208-525-6151
Practice Address - Street 1:2805 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7597
Practice Address - Country:US
Practice Address - Phone:208-552-3184
Practice Address - Fax:208-525-6151
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO 0374208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807431800Medicaid
1303142Medicare ID - Type Unspecified
ID807431800Medicaid