1669587630 NPI number — GARRETT B SMITH DO

Table of content: GARRETT B SMITH DO (NPI 1669587630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669587630 NPI number — GARRETT B SMITH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
GARRETT
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669587630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 N 2000 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANT GROVE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84062-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-756-3511
Provider Business Mailing Address Fax Number:
801-756-1705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W 200 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84042-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-796-1333
Provider Business Practice Location Address Fax Number:
801-443-1164
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  57067131204 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107031736101 . This is a "SELECTHEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870293873GBS . This is a "EMI HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: IDX35650 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57067131202001 . This is a "BLUE CROSS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 908424 . This is a "DESERET HEALTHCARE TRUST" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 225991 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 87029387384062A003 . This is a "TRICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: D5969 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80400 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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