Provider Demographics
NPI:1285602508
Name:SMITH, DOUGLAS C (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
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:PO BOX 241769
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1769
Mailing Address - Country:US
Mailing Address - Phone:907-770-2380
Mailing Address - Fax:907-770-2341
Practice Address - Street 1:2900 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5756
Practice Address - Country:US
Practice Address - Phone:907-345-0728
Practice Address - Fax:907-345-0728
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2227208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
920128597OtherFEDERAL TAX ID
A0328OtherBLUE CROSS SUB
AKMD0658Medicaid
C96945Medicare UPIN
AK0000BHWXLMedicare ID - Type Unspecified