1154485985 NPI number — DR. PETER ROY SMETHURST MD

Table of content: DR. PETER ROY SMETHURST MD (NPI 1154485985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154485985 NPI number — DR. PETER ROY SMETHURST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMETHURST
Provider First Name:
PETER
Provider Middle Name:
ROY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154485985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 W LA VETA AVE STE 750
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-639-9401
Provider Business Mailing Address Fax Number:
714-919-8804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 W LA VETA AVE STE 750
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-4312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-639-9401
Provider Business Practice Location Address Fax Number:
714-919-8804
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A77515 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: A77515 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: A77515 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0003350 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1912919804 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG5665 . This is a "RAILROAD MEDICARE - GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1912919804 . This is a "NPI - TYPE 2" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00855924 . This is a "RAILROAD MEDICARE - PROVIDER PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W1514 . This is a "MEDICARE PTAN - TYPE 2" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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