Provider Demographics
NPI:1447249131
Name:SMITH, JOHN QUENTIN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:QUENTIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1906 FAIRVIEW AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5424
Mailing Address - Country:US
Mailing Address - Phone:208-459-4511
Mailing Address - Fax:208-459-6602
Practice Address - Street 1:1906 FAIRVIEW AVE STE 400
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5424
Practice Address - Country:US
Practice Address - Phone:208-459-4511
Practice Address - Fax:208-459-6602
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM8626207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806427100Medicaid
G52276Medicare UPIN