1609211291 NPI number — CLARISA I. SMITH, MD PLLC

Table of content: (NPI 1609211291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609211291 NPI number — CLARISA I. SMITH, MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARISA I. SMITH, MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
YAVAPAI PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1609211291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 CHESTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21403-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-431-1152
Provider Business Mailing Address Fax Number:
602-431-2149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1C
Provider Business Practice Location Address City Name:
PRESCOTT VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86314-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-458-5470
Provider Business Practice Location Address Fax Number:
928-458-5979
Provider Enumeration Date:
05/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SORENSEN
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
602-431-1152

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  35537 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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