Provider Demographics
NPI:1710904636
Name:SAM P SMITH DO LLC
Entity Type:Organization
Organization Name:SAM P SMITH DO LLC
Other - Org Name:SAM P SMITH DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-369-6845
Mailing Address - Street 1:4915 E BASELINE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2965
Mailing Address - Country:US
Mailing Address - Phone:480-646-8660
Mailing Address - Fax:480-646-8665
Practice Address - Street 1:4915 E BASELINE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2965
Practice Address - Country:US
Practice Address - Phone:480-646-8660
Practice Address - Fax:480-646-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4237207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110914Medicare PIN