Provider Demographics
NPI:1568476596
Name:SMITH, ELOWYN M (DO)
Entity type:Individual
Prefix:MRS
First Name:ELOWYN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:SUITE 233
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7184
Mailing Address - Country:US
Mailing Address - Phone:907-357-4543
Mailing Address - Fax:907-357-4533
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 233
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-357-4543
Practice Address - Fax:907-357-4533
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AKAK5154208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK5469Medicaid
AK152839Medicare ID - Type Unspecified
AKH96087Medicare UPIN