Provider Demographics
NPI:1700830601
Name:SMITH, LEROY CARTER (MD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:CARTER
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 SILVER CREEK RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7904
Mailing Address - Country:US
Mailing Address - Phone:928-704-7163
Mailing Address - Fax:928-704-7140
Practice Address - Street 1:2755 SILVER CREEK RD
Practice Address - Street 2:SUITE 111
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7904
Practice Address - Country:US
Practice Address - Phone:928-704-7163
Practice Address - Fax:928-704-7140
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26371207QA0505X, 207QG0300X
AZ41584208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8977958Medicaid
AZ412862Medicaid
AZZ128397Medicare PIN
AZ412862Medicaid