Provider Demographics
NPI:1497809396
Name:SMITH, DOUGLAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
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 5250
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90721-5250
Mailing Address - Country:US
Mailing Address - Phone:562-596-6837
Mailing Address - Fax:
Practice Address - Street 1:12340 SEAL BEACH BLVD # B641
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-2792
Practice Address - Country:US
Practice Address - Phone:562-596-6837
Practice Address - Fax:562-596-6837
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42932207N00000X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05D0554803OtherCMS CLIA
CA00G429321Medicaid
CA00G429320Medicaid
CA00G429320Medicaid
05D0554803OtherCMS CLIA
G42932Medicare ID - Type Unspecified