Provider Demographics
NPI:1861448664
Name:SMITH, RICHARD LEE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:ATTN: JEAN STEELE
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-9998
Mailing Address - Fax:660-542-9880
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-9998
Practice Address - Fax:660-542-9880
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208178913Medicaid
MOG22606Medicare UPIN
MOW60000001Medicare PIN