Basic Information
Provider Information | |||||||||
NPI: | 1992020481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | CARLSEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | PATRICK | ||||||||
OtherMiddleName: | CARLSEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D., M.P.H. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1012 BELMONT AVE | ||||||||
Address2: |   | ||||||||
City: | LA JUNTA | ||||||||
State: | CO | ||||||||
PostalCode: | 810502101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193835900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1012 BELMONT AVE | ||||||||
Address2: |   | ||||||||
City: | LA JUNTA | ||||||||
State: | CO | ||||||||
PostalCode: | 810502101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193835900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2010 | ||||||||
LastUpdateDate: | 01/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 50367 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 96223073 | 05 | CO |   | MEDICAID |