Provider Demographics
NPI:1174848337
Name:SMITH, NATHANIEL EVAN
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:EVAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-1921
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR DEPT OF
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1845
Practice Address - Fax:210-916-3235
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27673207ND0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology