Provider Demographics
NPI:1992774525
Name:SMITH, SANDRA L (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:402-398-6248
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 420
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3203
Practice Address - Country:US
Practice Address - Phone:360-514-6161
Practice Address - Fax:360-514-6140
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE29835208600000X
WAMD61154801208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4645836Medicaid
MI000370031OtherBCBSM
MI4337963Medicaid
MIE85377Medicare UPIN
MI0N99620Medicare ID - Type Unspecified
MI4337963Medicaid