Basic Information
| Provider Information | |||||||||
| NPI: | 1437103157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19420 N 59TH AVE | ||||||||
| Address2: | SUITE B233 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232342542 | ||||||||
| FaxNumber: | 6232342543 | ||||||||
| Practice Location | |||||||||
| Address1: | 490B W ZIA RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059958346 | ||||||||
| FaxNumber: | 5059958345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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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 | 2086S0129X | 93154 | NM | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 700521083 | 01 | MEDICARE GROUP NUMBER | OTHER |