Basic Information
| Provider Information | |||||||||
| NPI: | 1710954375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 GAGE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993529532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099422555 | ||||||||
| FaxNumber: | 5099422340 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 GOETHALS DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 3083326-1205 | UT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | MD00044139 | WA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207V00000X | MD00044139 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0272100 | 01 | WA | LABOR & INDUSTRIES | OTHER |