Provider Demographics
NPI:1497709349
Name:SMITH, WILLIAM BERWYN (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BERWYN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W
Other - Middle Name:BERWYN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:41877 ENTERPRISE CIR N
Mailing Address - Street 2:STE 110
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5656
Mailing Address - Country:US
Mailing Address - Phone:951-296-2244
Mailing Address - Fax:951-296-5734
Practice Address - Street 1:41877 ENTERPRISE CIR N
Practice Address - Street 2:STE 110
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5656
Practice Address - Country:US
Practice Address - Phone:951-296-2244
Practice Address - Fax:951-296-3604
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28719207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00628719Medicaid
CA180013990OtherRAILROAD MEDICARE
CA00628719Medicaid
CA180013990OtherRAILROAD MEDICARE