Provider Demographics
NPI:1518961440
Name:SMITH, PETER GAILLARD (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GAILLARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:STE 597A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8214
Mailing Address - Country:US
Mailing Address - Phone:314-432-5151
Mailing Address - Fax:314-432-8795
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:STE 597A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8214
Practice Address - Country:US
Practice Address - Phone:314-432-5151
Practice Address - Fax:314-432-8795
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR8770207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12356Medicare UPIN
0000003435Medicare NSC