Provider Demographics
NPI:1174628804
Name:SMITH, GREGG LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:LEWIS
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 1:852 W HIGHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-1543
Mailing Address - Country:US
Mailing Address - Phone:909-624-4421
Mailing Address - Fax:
Practice Address - Street 1:550 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8160
Practice Address - Country:US
Practice Address - Phone:707-826-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG075567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD000Medicare UPIN