Provider Demographics
NPI:1346384864
Name:SMITH, DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:SMITH
Suffix:
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 1:165 N LA BREA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1707
Mailing Address - Country:US
Mailing Address - Phone:323-678-1111
Mailing Address - Fax:
Practice Address - Street 1:165 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1707
Practice Address - Country:US
Practice Address - Phone:323-678-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC37854207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC37854AOtherMEDICARE RENDERING NUMBER
CA00C378540Medicaid
CA00C378540Medicaid
CAA87977Medicare UPIN