Provider Demographics
NPI:1891751129
Name:SMITH, DOUGLAS D (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
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 1:8027 STRAWBERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-5399
Mailing Address - Country:US
Mailing Address - Phone:816-633-4199
Mailing Address - Fax:
Practice Address - Street 1:206 N BISMARK ST
Practice Address - Street 2:SUITE A
Practice Address - City:CONCORDIA
Practice Address - State:MO
Practice Address - Zip Code:64020-8180
Practice Address - Country:US
Practice Address - Phone:660-463-0234
Practice Address - Fax:660-463-0266
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9H22207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010568509Medicaid
MO540568508Medicaid
MO595956103Medicaid
14109027OtherBCBS
14109017OtherBCBS
MO202545364Medicaid
MO599225901Medicaid
14109077OtherBCBS
MO010568509Medicaid
14109027OtherBCBS
MO202545364Medicaid
MO540568508Medicaid
268578Medicare Oscar/Certification
268548Medicare Oscar/Certification
MOMA4680022Medicare PIN
E24105Medicare UPIN
P00182425Medicare PIN