Provider Demographics
NPI:1144252099
Name:SMITH, DEAN TY (DO)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:TY
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:D.
Other - Middle Name:TY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-7869
Practice Address - Street 1:79 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:ID
Practice Address - Zip Code:83234-4703
Practice Address - Country:US
Practice Address - Phone:208-897-5600
Practice Address - Fax:208-897-5603
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002812000Medicaid
IDF79656Medicare UPIN
ID1301325Medicare PIN