Provider Demographics
NPI:1285849778
Name:SMITH, PETER JORDAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JORDAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 ACTON ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-2109
Mailing Address - Country:US
Mailing Address - Phone:510-548-7278
Mailing Address - Fax:
Practice Address - Street 1:826 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94707-2020
Practice Address - Country:US
Practice Address - Phone:510-524-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5328171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5328OtherSTATE ACUPUNCTURE LICENSE
CAAC0053280Medicare ID - Type UnspecifiedMEDICARE