Provider Demographics
NPI:1215965728
Name:SMITH, DEBRA J (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 10100
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0008
Mailing Address - Country:US
Mailing Address - Phone:970-874-7225
Mailing Address - Fax:
Practice Address - Street 1:1501 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40532207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61336319Medicaid
COH25268Medicare UPIN
CO804201Medicare ID - Type Unspecified
CO61336319Medicaid