Provider Demographics
NPI:1154528727
Name:SMITH, JOSHUA MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3910 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-523-1122
Mailing Address - Fax:208-523-2582
Practice Address - Street 1:3910 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7596
Practice Address - Country:US
Practice Address - Phone:208-523-1122
Practice Address - Fax:208-523-2582
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30283208000000X
GA63960208000000X
TXN8989208000000X, 2080P0205X
IDM135042080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1154528727Medicaid
TX312219409Medicaid
TX312219410Medicaid
TX267859YZXYMedicare PIN