Provider Demographics
NPI:1194091041
Name:SMITH, MARTIN D (RD, LD)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-9441
Mailing Address - Fax:800-591-0121
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-9441
Practice Address - Fax:800-591-0121
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK280133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered