Provider Demographics
NPI:1639131386
Name:SMITH, LARRY DEAN (DO)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DEAN
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0071
Mailing Address - Country:US
Mailing Address - Phone:509-634-2995
Mailing Address - Fax:509-634-2945
Practice Address - Street 1:617 BENTON ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-422-7416
Practice Address - Fax:509-634-2945
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001346207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1078310Medicaid
WAG8886888OtherMEDICARE PTAN
0264988OtherL&I
0264988OtherL&I