Provider Demographics
NPI:1669559209
Name:SMITH, TERRY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:GLEN
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:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-2650
Mailing Address - Country:US
Mailing Address - Phone:808-885-5236
Mailing Address - Fax:808-885-4126
Practice Address - Street 1:67-1123 MAMALAHOA HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8451
Practice Address - Country:US
Practice Address - Phone:808-885-5236
Practice Address - Fax:808-885-4126
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI6367207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIK07806-9OtherHMSA PROVIDER NUMBER
HI522260Medicaid
HIE21269Medicare ID - Type Unspecified
HIK07806-9OtherHMSA PROVIDER NUMBER