Provider Demographics
NPI:1710980206
Name:SMOCK, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:SMOCK
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 1:1837 S MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-5250
Mailing Address - Country:US
Mailing Address - Phone:831-596-1629
Mailing Address - Fax:
Practice Address - Street 1:11274 S FORTUNA RD STE I4
Practice Address - Street 2:558 ABBOTT ST STE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7849
Practice Address - Country:US
Practice Address - Phone:928-345-2150
Practice Address - Fax:928-345-2151
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54922208D00000X
AZ24675207Q00000X
MO2003017056207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ28500Medicare ID - Type UnspecifiedGROUP NUMBER
AZG89545Medicare UPIN