Provider Demographics
NPI:1821879933
Name:SMITH, MICHAEL BRIAN (NMD, MS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:NMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 CHANNING WAY # 323
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8034
Mailing Address - Country:US
Mailing Address - Phone:208-252-5188
Mailing Address - Fax:
Practice Address - Street 1:1547 MIDWAY AVE STE B
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6912
Practice Address - Country:US
Practice Address - Phone:208-252-5188
Practice Address - Fax:844-556-5990
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNMD-0074175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath