Provider Demographics
NPI:1366469942
Name:SMILE, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:SMILE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 STONY POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401
Mailing Address - Country:US
Mailing Address - Phone:707-521-4500
Mailing Address - Fax:707-544-4626
Practice Address - Street 1:144 STONY POINT ROAD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:707-521-4500
Practice Address - Fax:707-544-4626
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549200Medicaid
CA00A549200Medicare ID - Type Unspecified
CA00A549200Medicaid