Provider Demographics
NPI:1174681928
Name:SMITH, DOUGLAS ROLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ROLAND
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 1:4417 S DORIS WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3525
Mailing Address - Country:US
Mailing Address - Phone:801-682-6817
Mailing Address - Fax:
Practice Address - Street 1:4544 S HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4404
Practice Address - Country:US
Practice Address - Phone:801-682-6817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56913841205207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
005531342Medicare PIN
UT000063528Medicare PIN
005506625Medicare PIN
I20509Medicare UPIN
005528175Medicare PIN
005522047Medicare PIN