Provider Demographics
NPI:1336257617
Name:SMITH, SCOTT L (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
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 1:830 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4047
Mailing Address - Country:US
Mailing Address - Phone:801-756-3511
Mailing Address - Fax:801-443-1164
Practice Address - Street 1:830 N 2000 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4047
Practice Address - Country:US
Practice Address - Phone:801-756-3511
Practice Address - Fax:801-443-1164
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1804361205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT09661Medicaid
UT18687OtherPEHP
UT5556OtherDESERET HEALTHCARE TRUST
UTQMXAF01481OtherALTIUS
UT870293873SM1OtherEMIA
UT107007402101OtherSELECT HEALTH
UT87029387384062B004OtherTRICARE
UT107007402101OtherSELECT HEALTH
UT000004509Medicare ID - Type UnspecifiedMEDICARE
UT080027671Medicare ID - Type UnspecifiedRAILROAD MEDICARE