Provider Demographics
NPI:1629371034
Name:SMITH, DEBORAH JANE (LD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DEMOSS STREET
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8367
Practice Address - Street 1:1007 N POPE ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5161
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-388-3465
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMAAA0103OtherMEDICARE PTAN
NM98633708Medicaid
NMAAA0103OtherMEDICARE PTAN