Provider Demographics
NPI:1942347364
Name:SMITH, IAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 278
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-625-5160
Practice Address - Fax:208-625-5733
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11282207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039084400Medicaid
MD207258ZAK8Medicare PIN