Basic Information
| Provider Information | |||||||||
| NPI: | 1497869580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRADFORD | ||||||||
| MiddleName: | DOUGLASS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 NORTH CENTER ST | ||||||||
| Address2: | #800 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840437406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901911 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 8TH AVENUE AND C STREET | ||||||||
| Address2: | LDS HOSPITAL | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015075248 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4977139-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 107027622101 | 01 | UT | IHC | OTHER | 77514 | 01 | UT | PEHP | OTHER | 850715 | 01 | UT | DESERET MUTUAL | OTHER | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 806852300 | 05 | ID | MEDICAID | QM0000075886 | 01 | UT | ALTIUS | OTHER | 1502954 | 01 | UT | UMWA | OTHER | 870545614BDS | 01 | UT | EDUCATORS MUTUAL | OTHER | 100503114 | 05 | NV | MEDICAID | 49771391200001 | 01 | UT | BCBS | OTHER | 119554900 | 05 | WY | MEDICAID | 70622 | 01 | UT | HEALTHY U | OTHER | 855398 | 05 | AZ | MEDICAID | TPRA09322 | 01 | UT | MOLINA | OTHER |