Provider Demographics
NPI:1912916479
Name:SMITH, BRAD V (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:V
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 4046
Mailing Address - Street 2:#540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 S. NATIONAL AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3423207R00000X
OK18409207R00000X
MO2006024382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148194001Medicaid
211845OtherBLUE CROSS OF MO
MO203628904Medicaid
G05220Medicare UPIN
P00362876Medicare PIN
AR148194001Medicaid
962211890Medicare PIN
MO203628904Medicaid
211845OtherBLUE CROSS OF MO