Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1100X | Ophthalmic | COA |
NPI | 1306519541 |
---|---|
Provider Name | Samuel Smith |
First Address | Durango, CO 81301-4161 |
Second Address | Albuquerque, NM 87108-5153 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2021 |
Last Update Date | 25/07/2021 |