Provider Demographics
NPI:1154452795
Name:SMITH, JOSHUA CLETUS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:CLETUS
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 1:4932 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3727
Mailing Address - Country:US
Mailing Address - Phone:314-752-4679
Mailing Address - Fax:
Practice Address - Street 1:1600 S BRENTWOOD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-1301
Practice Address - Country:US
Practice Address - Phone:314-918-8827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007006308208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics