Provider Demographics
NPI:1225106230
Name:THOMAS E SMITH DPM
Entity Type:Organization
Organization Name:THOMAS E SMITH DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-599-0981
Mailing Address - Street 1:425 W BONITA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2543
Mailing Address - Country:US
Mailing Address - Phone:909-599-0981
Mailing Address - Fax:909-592-0738
Practice Address - Street 1:425 W BONITA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:909-592-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2504213EP0504X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20893OtherMEDICARE PTAN
CAGRE000060Medicaid
CADG3139OtherPALMETTO GBA
CAGRE000060Medicaid
CAWE2504CMedicare PIN