Provider Demographics
NPI:1720072697
Name:SMOOT, SANFORD (MD)
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:
Last Name:SMOOT
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 1:18 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-1917
Mailing Address - Country:US
Mailing Address - Phone:781-862-1429
Mailing Address - Fax:
Practice Address - Street 1:18 HOLMES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-1917
Practice Address - Country:US
Practice Address - Phone:781-862-1429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA519662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3130576Medicaid
MA3130576Medicaid
MAJ09059Medicare ID - Type Unspecified