Provider Demographics
NPI:1639348899
Name:SMITH, STACY RUTH (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RUTH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
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 27688
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0688
Mailing Address - Country:US
Mailing Address - Phone:801-534-1360
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:1548 E 4500 S STE 105
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5209
Practice Address - Country:US
Practice Address - Phone:801-424-3090
Practice Address - Fax:801-424-3091
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6024879-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology