Provider Demographics
NPI:1992830111
Name:SMITH, DONALD LEE
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12349 FRONTAGE RD
Mailing Address - Street 2:P.O.B.426
Mailing Address - City:YUCCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86438-0426
Mailing Address - Country:US
Mailing Address - Phone:928-208-0254
Mailing Address - Fax:928-766-2363
Practice Address - Street 1:12349 FRONTAGE RD
Practice Address - Street 2:P.O.B.426
Practice Address - City:YUCCA
Practice Address - State:AZ
Practice Address - Zip Code:86438-0426
Practice Address - Country:US
Practice Address - Phone:928-208-0254
Practice Address - Fax:928-766-2363
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7275614172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164739OtherAHCCCS PROVIDER #