Provider Demographics
NPI:1043326192
Name:SMITH, GINA LARAINE (MD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:LARAINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:
Practice Address - Street 1:9015 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2444
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-714-3755
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036105255207Q00000X
AZ74097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ174811Medicaid
MI1043326192Medicaid