1124107925 NPI number — STEPHEN DOUGLAS SMITH DPM FACFAS

Table of content: STEPHEN DOUGLAS SMITH DPM FACFAS (NPI 1124107925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124107925 NPI number — STEPHEN DOUGLAS SMITH DPM FACFAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
STEPHEN
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM FACFAS
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:
1124107925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 W ROMNEYA DR
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92801-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-991-3333
Provider Business Mailing Address Fax Number:
714-991-6059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14641 NEWPORT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-991-3333
Provider Business Practice Location Address Fax Number:
714-991-6059
Provider Enumeration Date:
11/03/2006

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: 213ES0103X , with the licence number:  E2588 , 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)





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