Basic Information
| Provider Information | |||||||||
| NPI: | 1609189257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALLEY | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59TH MEDICAL WING | ||||||||
| Address2: | 1100 WILFORD HALL LOOP | ||||||||
| City: | JBSA LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102923725 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 SCHOFIELD RD | ||||||||
| Address2: | BLDG 1179 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782347577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109163160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080A0000X | 20A 12264 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.