Provider Demographics
NPI:1225107824
Name:SMITH, RICHARD B (MD,)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
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 1:603 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-622-1477
Mailing Address - Fax:575-622-4023
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-622-1477
Practice Address - Fax:575-633-4023
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM771042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10744Medicaid
NM201009406OtherPRESBYTERIAN PROVIDER ID
NM10744Medicaid
NM348226102Medicare UPIN