Provider Demographics
NPI:1174546691
Name:SMITH, BRENT WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:WILLIAM
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 1:101 BODIN CIR
Mailing Address - Street 2:2C614
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-3774
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:2C614
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-3774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059966A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine