Basic Information
Provider Information | |||||||||
NPI: | 1346467115 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMALLEY | ||||||||
FirstName: | AARON | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1735 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846041010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013792925 | ||||||||
FaxNumber: | 8013792959 | ||||||||
Practice Location | |||||||||
Address1: | 220 N 1200 E | ||||||||
Address2: | STE 101 | ||||||||
City: | LEHI | ||||||||
State: | UT | ||||||||
PostalCode: | 840435862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013416200 | ||||||||
FaxNumber: | 8017663289 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2007 | ||||||||
LastUpdateDate: | 01/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 6914436-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 87-0283576 | 05 | UT |   | MEDICAID |