Provider Demographics
NPI: | 1578592895 |
---|---|
Name: | SMITH, BRYAN MATTHEW (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRYAN |
Middle Name: | MATTHEW |
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: | 5767 W CENTURY BLVD STE 400 |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90045-5631 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10833 LE CONTE AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOS ANGELES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90095-3075 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-319-1234 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-30 |
Last Update Date: | 2018-10-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 125.062786 | 207X00000X |
OK | 3952 | 225100000X |
390200000X | ||
CA | A156007 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |