Provider Demographics
NPI:1376599191
Name:SMITH, ERIC DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DAVID
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-8082
Practice Address - Street 1:3301 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-3803
Practice Address - Country:US
Practice Address - Phone:650-364-3080
Practice Address - Fax:650-364-2004
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA686062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08255024Medicaid
WA300134148OtherRAILROAD MEDICARE
WA5578SMOtherREGENCE BLUE SHIELD
WA8905618OtherL&I; CVCP
NV1376599191Medicaid
CA300134150OtherRAILROAD MEDICARE
AZ912841Medicaid
CA00A686060Medicaid
WA9413833Medicaid
WA0212626OtherL&I
WA8905618OtherL&I; CVCP
WA9413833Medicaid
COCO300513Medicare PIN
CACT102TMedicare PIN
CACT102WMedicare PIN
WA300134148OtherRAILROAD MEDICARE
CACT102UMedicare PIN
CA00A686067Medicare PIN
CA00A686068Medicare PIN
CA300134150OtherRAILROAD MEDICARE
WA0212626OtherL&I
WA5578SMOtherREGENCE BLUE SHIELD
WA8851365Medicare PIN
CA00A686066Medicare PIN
CA00A6860615Medicare PIN
CA00A6860613Medicare PIN
NE281635Medicare PIN
CA00A6860622Medicare PIN