1548259385 NPI number — JOHN P SMITH MD A PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548259385 NPI number — JOHN P SMITH MD A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN P SMITH MD A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NATIONAL AVENUE MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1548259385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1530 MONTEVAL PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95120-5714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-406-1895
Provider Business Mailing Address Fax Number:
408-268-7814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14911 NATIONAL AVE
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95032-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-358-3448
Provider Business Practice Location Address Fax Number:
408-356-4628
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
408-406-1895

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0082830 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CF8105 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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