Provider Demographics
NPI:1225029804
Name:SMITH, ELLEN MEG (DO)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MEG
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:ESPARZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:14202 CRYSTAL VIEW TER
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-8707
Mailing Address - Country:US
Mailing Address - Phone:951-907-4539
Mailing Address - Fax:
Practice Address - Street 1:81767 DR CARREON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5599
Practice Address - Country:US
Practice Address - Phone:760-625-0569
Practice Address - Fax:760-777-4339
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAP943ZMedicare PIN