Provider Demographics
NPI:1790769693
Name:SMITH, ROBERT EDWIN (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWIN
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 1:518 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-4517
Mailing Address - Country:US
Mailing Address - Phone:505-396-5336
Mailing Address - Fax:505-396-7291
Practice Address - Street 1:518 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4517
Practice Address - Country:US
Practice Address - Phone:505-396-5336
Practice Address - Fax:505-396-7291
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA536-69207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine