Provider Demographics
NPI:1164532750
Name:SMITH, ROBERTA J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:970 MONUMENT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3891
Mailing Address - Country:US
Mailing Address - Phone:310-459-4321
Mailing Address - Fax:310-459-5326
Practice Address - Street 1:970 MONUMENT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3891
Practice Address - Country:US
Practice Address - Phone:310-459-4321
Practice Address - Fax:310-459-5326
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG17205207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A40016Medicare UPIN
CAG17205Medicare ID - Type Unspecified