Provider Demographics
NPI:1427378595
Name:SMITH, JONATHAN ST PIERRE (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ST PIERRE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CAISSON HILL RD
Mailing Address - Street 2:DERMATOLOGY CLINIC IACH
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7037
Mailing Address - Country:US
Mailing Address - Phone:785-240-7766
Mailing Address - Fax:
Practice Address - Street 1:600 CAISSON HILL RD
Practice Address - Street 2:DERMATOLOGY CLINIC IACH
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7037
Practice Address - Country:US
Practice Address - Phone:785-240-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102203164207N00000X
MTMED-PHYS-LIC-48386207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000OtherUPIN