Provider Demographics
NPI:1811489131
Name:SMITH, BRENTON WALTER (MD)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:WALTER
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:590 MITCHELL BLVD BLDG 375
Mailing Address - Street 2:
Mailing Address - City:LAUGHLIN AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78843-5242
Mailing Address - Country:US
Mailing Address - Phone:830-298-6471
Mailing Address - Fax:
Practice Address - Street 1:590 MITCHELL BLVD BLDG 375
Practice Address - Street 2:
Practice Address - City:LAUGHLIN AFB
Practice Address - State:TX
Practice Address - Zip Code:78843-5242
Practice Address - Country:US
Practice Address - Phone:830-298-6471
Practice Address - Fax:910-907-6099
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN66657207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine