Provider Demographics
NPI:1750316188
Name:SMITH, MICAH JEREMY (DO)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:JEREMY
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 1:750 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3660
Mailing Address - Country:US
Mailing Address - Phone:801-714-6570
Mailing Address - Fax:801-714-6588
Practice Address - Street 1:750 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3660
Practice Address - Country:US
Practice Address - Phone:801-714-6570
Practice Address - Fax:801-714-6588
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6396674-1204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT63966741200001OtherBCBS
P00434283OtherRR
P00434283OtherRR
E86026140Medicare ID - Type Unspecified
UTI47861Medicare UPIN
UT$$$$$$$$$001Medicaid