Provider Demographics
NPI:1518069020
Name:SMITH, ALAN ROSS (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ROSS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:140 WHITE SAGE AVE
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:UT
Practice Address - Zip Code:84624-8928
Practice Address - Country:US
Practice Address - Phone:435-864-3333
Practice Address - Fax:435-864-2790
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT148272-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000010046Medicare ID - Type Unspecified
UTE69415Medicare UPIN