Provider Demographics
NPI:1164424479
Name:SMITH, ELDENE ARNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELDENE
Middle Name:ARNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57463 TWENTY-NINE PALMS HIGHWAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284
Mailing Address - Country:US
Mailing Address - Phone:760-228-1855
Mailing Address - Fax:760-228-1897
Practice Address - Street 1:57463 TWENTY-NINE PALMS HIGHWAY
Practice Address - Street 2:SUITE 203
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-228-1855
Practice Address - Fax:760-228-1897
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A389440Medicaid
CA00A389440Medicare ID - Type Unspecified
CA00A389440Medicaid