Provider Demographics
NPI:1528364098
Name:SMITH, ROBERT A (CO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:CO
Other - Prefix:MR
Other - First Name:BOBBY
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CO
Mailing Address - Street 1:190 N WIGET LANE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2417
Mailing Address - Country:US
Mailing Address - Phone:925-935-9194
Mailing Address - Fax:925-935-9194
Practice Address - Street 1:190 N WIGET LANE
Practice Address - Street 2:SUITE 109
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2417
Practice Address - Country:US
Practice Address - Phone:925-935-9194
Practice Address - Fax:925-935-9194
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002952222Z00000X
224P00000X, 225000000X, 246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0029520Medicaid