Provider Demographics
NPI:1962519785
Name:SMITH, CRAIG R (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:R
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-991-4644
Mailing Address - Fax:866-342-0133
Practice Address - Street 1:330 1ST CAPITOL DR STE 100A
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2846
Practice Address - Country:US
Practice Address - Phone:636-669-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108607208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203941307Medicaid
IL201703499OtherTIN
IL201703499OtherTIN
ILG90102Medicare UPIN