Provider Demographics
NPI:1316293889
Name:LEROUX SMITH, DEREK MIGUEL (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MIGUEL
Last Name:LEROUX 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 1:18432 KENRICK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9288
Mailing Address - Country:US
Mailing Address - Phone:952-992-6700
Mailing Address - Fax:
Practice Address - Street 1:2990 CENTRE POINTE DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1182
Practice Address - Country:US
Practice Address - Phone:651-638-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN575942084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty