Provider Demographics
NPI:1558779363
Name:SMITH, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 EAST PACIFIC COAST HWY SUITE #600
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-6914
Mailing Address - Country:US
Mailing Address - Phone:562-346-1119
Mailing Address - Fax:562-981-7604
Practice Address - Street 1:4510 E PACIFIC COAST HWY STE 600
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-6914
Practice Address - Country:US
Practice Address - Phone:562-346-1119
Practice Address - Fax:562-981-7604
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program