Provider Demographics
NPI:1275308025
Name:SMITH, ERNEST CLARENCE KOANI JR ((IDC))
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:CLARENCE KOANI
Last Name:SMITH
Suffix:JR
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 1:34101 FARENHOLT AVE BLDG 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-4856
Mailing Address - Country:US
Mailing Address - Phone:808-492-7003
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-4856
Practice Address - Country:US
Practice Address - Phone:808-492-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman