Provider Demographics
NPI:1104222876
Name:SMITH, MICHELLE L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5005, PMB #46
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTE FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067
Mailing Address - Country:US
Mailing Address - Phone:858-832-8963
Mailing Address - Fax:
Practice Address - Street 1:39400 PASEO PADRE PARKWAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:858-832-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG059152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine