Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 15223 | MO |
Y | 213EG0000X | General Practice | 15223 | MO |
NPI | 1003905928 |
---|---|
Provider Name | Bradley Joseph Smith |
First Address | Lees Summit, MO 64086-5696 |
Second Address | Lees Summit, MO 64086-5696 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 08/07/2007 |