Provider Demographics
NPI:1255490330
Name:SMITH, MARK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7695 CARDINAL CT STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3357
Mailing Address - Country:US
Mailing Address - Phone:858-609-7100
Mailing Address - Fax:858-609-7106
Practice Address - Street 1:7695 CARDINAL CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3357
Practice Address - Country:US
Practice Address - Phone:858-609-7100
Practice Address - Fax:858-609-7106
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG55641207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G556410Medicaid
E48422Medicare UPIN
CAWG55641CMedicare ID - Type Unspecified
CA00G556410Medicaid