Basic Information
Provider Information
NPI: 1003803925
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: GREGG
MiddleName: ALAN
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: SMITH
OtherFirstName: GREGG
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: D.O., PC
OtherLastNameType: 2
Mailing Information
Address1: 3928 E MINTON CIR
Address2:  
City: MESA
State: AZ
PostalCode: 852151727
CountryCode: US
TelephoneNumber: 4802426297
FaxNumber:  
Practice Location
Address1: 1042 N HIGLEY RD
Address2: SUITE 102-602
City: MESA
State: AZ
PostalCode: 852055398
CountryCode: US
TelephoneNumber: 4802426297
FaxNumber: 4806993129
Other Information
ProviderEnumerationDate: 10/05/2005
LastUpdateDate: 10/31/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X2813AZY Allopathic & Osteopathic PhysiciansInternal Medicine 
208M00000X2813AZN Allopathic & Osteopathic PhysiciansHospitalist 

ID Information
IDTypeStateIssuerDescription
161918465201 NPIOTHER
31819801AZAHCCCSOTHER


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