Provider Demographics
NPI:1265409643
Name:SMITH, SANDRA LYNN (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:SMITH
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:PO BOX 6033
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86011-0181
Mailing Address - Country:US
Mailing Address - Phone:928-523-2131
Mailing Address - Fax:928-523-1102
Practice Address - Street 1:824 S SAN FRANCISCO ST
Practice Address - Street 2:BLDG. #25 NAU
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-523-2131
Practice Address - Fax:928-523-1102
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G84452Medicare UPIN