Provider Demographics
NPI:1518908276
Name:SMITH, EDEN LOWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDEN
Middle Name:LOWELL
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 1:680 GUZZI LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5288
Mailing Address - Country:US
Mailing Address - Phone:209-536-1785
Mailing Address - Fax:209-536-1607
Practice Address - Street 1:680 GUZZI LN
Practice Address - Street 2:STE 201
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-536-1785
Practice Address - Fax:209-536-1607
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19148208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG191480Medicaid
CAA07687Medicare UPIN
CA00G191480Medicare ID - Type Unspecified