Basic Information
| Provider Information | |||||||||
| NPI: | 1538444674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | PRESTON | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2487 S GILBERT RD STE 106 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852952802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126498677 | ||||||||
| FaxNumber: | 4805644904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1464 E WHITESTONE BLVD STE 601 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786139066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126498677 | ||||||||
| FaxNumber: | 5127721692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2011 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036135650 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 036135650 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | R2979 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.