Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 2813 | AZ |
Y | 111NI0900X | Internist | 2813 | AZ |
NPI | 1003803925 |
---|---|
Provider Name | Gregg Alan Smith |
First Address | Mesa, AZ 85215-1727 |
Second Address | Mesa, AZ 85205-5398 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2005 |
Last Update Date | 31/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1619184652 | NPI (01) | |
318198 | AHCCCS (01) | AZ |
F66758 | (02) |