Provider Demographics
NPI:1790747046
Name:SMART, GARY W (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:SMART
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 ROARING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3778
Mailing Address - Country:US
Mailing Address - Phone:207-797-8262
Mailing Address - Fax:
Practice Address - Street 1:597 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5412
Practice Address - Country:US
Practice Address - Phone:207-774-7242
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET314439Medicare UPIN
MESM-015-257Medicare ID - Type Unspecified