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: | |||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2813 | AZ | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 2813 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619184652 | 01 | NPI | OTHER | 318198 | 01 | AZ | AHCCCS | OTHER |