Provider Demographics
NPI:1881669885
Name:SMITH, DOUGLAS LANE (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LANE
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 1:2131 E SOUTHERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:480-820-1200
Mailing Address - Fax:480-820-5743
Practice Address - Street 1:2131 E SOUTHERN AVENUE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-820-1200
Practice Address - Fax:480-820-5743
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32793207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7449611OtherAETNA
AZ0757140OtherBLUE CROSS
AZ865389Medicaid
H57459Medicare UPIN
AZ865389Medicaid