Provider Demographics
NPI:1801912985
Name:SMITH, SANDRA JEAN (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:STORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-507-2430
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:1280 E CALVADA BLVD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-5693
Practice Address - Country:US
Practice Address - Phone:775-751-3377
Practice Address - Fax:775-751-2323
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1801912985Medicaid
NVAS703XMedicare PIN
NVAS702YMedicare PIN