Provider Demographics
NPI:1255489159
Name:SMITH, DELANEY EDWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:DELANEY
Middle Name:EDWARD
Last Name:SMITH
Suffix:JR
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 1:1700 E WALNUT AVE
Mailing Address - Street 2:#250
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2605
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:1401 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3010
Practice Address - Country:US
Practice Address - Phone:310-301-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG403812083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G403810Medicaid
CA00G403810Medicaid