Provider Demographics
NPI:1114357605
Name:STACY R SMITH, MD APC
Entity Type:Organization
Organization Name:STACY R SMITH, MD APC
Other - Org Name:CALIFORNIA DERMATOLOGY & CLINICAL RESEARCH INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-203-3839
Mailing Address - Street 1:561 SAXONY PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-7700
Mailing Address - Country:US
Mailing Address - Phone:760-203-3839
Mailing Address - Fax:760-203-3840
Practice Address - Street 1:2371 LAGOON VIEW DR
Practice Address - Street 2:
Practice Address - City:CARDIFF
Practice Address - State:CA
Practice Address - Zip Code:92007-1507
Practice Address - Country:US
Practice Address - Phone:619-787-5723
Practice Address - Fax:619-342-7428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65407207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG04257Medicare UPIN