Provider Demographics
NPI:1881629202
Name:SMITH, CRAIG M (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5095
Mailing Address - Fax:208-367-5099
Practice Address - Street 1:5959 N DISCOVERY PLACE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1556
Practice Address - Country:US
Practice Address - Phone:208-367-5095
Practice Address - Fax:208-367-5099
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12444207QS0010X
SD4025207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5607412Medicaid
SDP00224840OtherRAILROAD MEDICARE
F75777Medicare UPIN
SD41821Medicare ID - Type Unspecified