Provider Demographics
NPI:1447690904
Name:SMITH, BRODI (DO)
Entity type:Individual
Prefix:
First Name:BRODI
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7597
Mailing Address - Country:US
Mailing Address - Phone:208-535-8422
Mailing Address - Fax:208-525-6151
Practice Address - Street 1:2805 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-535-8422
Practice Address - Fax:208-525-6151
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1114208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery