Provider Demographics
NPI:1548277197
Name:SMITH, ALBERT GORDON (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:GORDON
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 1:30 N 1900 E
Mailing Address - Street 2:SOM 3R152
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-2305
Mailing Address - Country:US
Mailing Address - Phone:801-585-5884
Mailing Address - Fax:801-585-2054
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:SOM 3R152
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-2305
Practice Address - Country:US
Practice Address - Phone:801-585-5884
Practice Address - Fax:801-585-2054
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT34279312052084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG52162Medicare UPIN