Provider Demographics
NPI:1235194135
Name:SMITH, GORDON ARTHUR (IDC)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ARTHUR
Last Name:SMITH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12083 CALLE DE MONTANA
Mailing Address - Street 2:220
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4913
Mailing Address - Country:US
Mailing Address - Phone:619-553-8998
Mailing Address - Fax:
Practice Address - Street 1:USS HELENA SSN 725
Practice Address - Street 2:
Practice Address - City:APO-AP
Practice Address - State:CA
Practice Address - Zip Code:96667-2405
Practice Address - Country:US
Practice Address - Phone:619-553-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman