Provider Demographics
NPI:1427010594
Name:SMILDE, RENEE INGEBORG (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:INGEBORG
Last Name:SMILDE
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:PO BOX 87729
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92138-7729
Mailing Address - Country:US
Mailing Address - Phone:619-285-5990
Mailing Address - Fax:
Practice Address - Street 1:4077 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-294-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70175207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A701750Medicaid
CA00A701750Medicaid
CAWA70175AMedicare ID - Type Unspecified