Provider Demographics
NPI:1407411762
Name:SMOCK, RON
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:SMOCK
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:PO BOX 95708
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-5708
Mailing Address - Country:US
Mailing Address - Phone:505-362-8039
Mailing Address - Fax:
Practice Address - Street 1:4213 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1103
Practice Address - Country:US
Practice Address - Phone:505-255-1090
Practice Address - Fax:595-345-5799
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM32D-0000011291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory