Provider Demographics
NPI:1255510285
Name:SMOCK, KRISTI JOHNSON (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:JOHNSON
Last Name:SMOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 CHIPETA WAY
Mailing Address - Street 2:MAIL STOP 115-G04
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-583-2787
Mailing Address - Fax:801-585-3831
Practice Address - Street 1:500 CHIPETA WAY
Practice Address - Street 2:MAIL STOP 115-G04
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-583-2787
Practice Address - Fax:801-585-3831
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5756815-1205207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP009708556OtherRAILROAD MEDICARE