Provider Demographics
NPI:1194797662
Name:SMITH, JACK ARLYN (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ARLYN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11060 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-1711
Mailing Address - Country:US
Mailing Address - Phone:907-346-2839
Mailing Address - Fax:
Practice Address - Street 1:4001 DALE ST
Practice Address - Street 2:#201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5428
Practice Address - Country:US
Practice Address - Phone:907-561-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0959207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0959Medicaid
AK0000BHCFHMedicare ID - Type Unspecified