Basic Information
| Provider Information | |||||||||
| NPI: | 1023169109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOUGLAS CARTER SMITH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOUGLAS CARTER SMITH, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 241769 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995241769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077702380 | ||||||||
| FaxNumber: | 9077702325 | ||||||||
| Practice Location | |||||||||
| Address1: | 17741 MOUNTAINSIDE VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995165756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073450728 | ||||||||
| FaxNumber: | 9073450728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | BEATY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 9077702301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 112749 | AK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MGD157 | 05 | AK | MEDICAID |