Basic Information
| Provider Information | |||||||||
| NPI: | 1114282175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CLAYTON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1217 BONITA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872958 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1217 BONITA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872958 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2012 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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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 | 207Q00000X | A-1852-15 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.