Provider Demographics
NPI:1275544322
Name:SMITH, MERLYN DEAN (DO)
Entity Type:Individual
Prefix:
First Name:MERLYN
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:606 N COUNTRY CLUB DR
Mailing Address - Street 2:#1 CLINIC OF PHYSICIANS AND SURGEONS
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5700
Mailing Address - Country:US
Mailing Address - Phone:480-733-4400
Mailing Address - Fax:480-969-0976
Practice Address - Street 1:606 N COUNTRY CLUB DR
Practice Address - Street 2:#1 CLINIC OF PHYSICIANS AND SURGEONS
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5700
Practice Address - Country:US
Practice Address - Phone:480-733-4400
Practice Address - Fax:480-969-0976
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2010207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ278350Medicaid
D43315Medicare UPIN
08WCFCX04Medicare ID - Type Unspecified