Basic Information
| Provider Information | |||||||||
| NPI: | 1639348899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | RUTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27688 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015341360 | ||||||||
| FaxNumber: | 8013669883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1548 E 4500 S STE 105 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841175209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014243090 | ||||||||
| FaxNumber: | 8014243091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 6024879-1205 | UT | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.