Provider Demographics
NPI:1013972157
Name:SMITH, TERRY PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:PAUL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 540610
Mailing Address - Street 2:
Mailing Address - City:N SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0610
Mailing Address - Country:US
Mailing Address - Phone:801-451-6060
Mailing Address - Fax:801-451-6060
Practice Address - Street 1:82 S 1100 E
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1686
Practice Address - Country:US
Practice Address - Phone:801-505-5277
Practice Address - Fax:801-505-5280
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1027420501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1013972157Medicaid
UT0590750001Medicare NSC
UT000063661Medicare PIN
UT1013972157Medicaid