Provider Demographics
NPI:1205085412
Name:SMITH, GEORGE WJ (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:WJ
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 1:5457 COTTONWOOD CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7549
Mailing Address - Country:US
Mailing Address - Phone:801-277-4941
Mailing Address - Fax:
Practice Address - Street 1:5457 COTTONWOOD CLUB DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7549
Practice Address - Country:US
Practice Address - Phone:801-277-4941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14349312052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry