Basic Information
Provider Information
NPI: 1003802968
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: STANLEY
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1000 AINSWORTH DR
Address2: SUITE 115
City: PRESCOTT
State: AZ
PostalCode: 863051667
CountryCode: US
TelephoneNumber: 9287781971
FaxNumber: 9284438473
Practice Location
Address1: 1000 AINSWORTH DR
Address2: SUITE 115
City: PRESCOTT
State: AZ
PostalCode: 863051667
CountryCode: US
TelephoneNumber: 9287781971
FaxNumber: 9284438473
Other Information
ProviderEnumerationDate: 09/26/2005
LastUpdateDate: 07/25/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X34173AZN Other Service ProvidersSpecialist 
2085R0202X34173AZY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
90792505AZ MEDICAID


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