Provider Demographics
NPI:1609979822
Name:SMITH, LARRY ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 4TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404
Mailing Address - Country:US
Mailing Address - Phone:707-526-4777
Mailing Address - Fax:707-526-8809
Practice Address - Street 1:1041 4TH ST
Practice Address - Street 2:STE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-526-4777
Practice Address - Fax:707-526-8809
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000E21510213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7704019Medicaid
CA7704019Medicaid
CA1609979822Medicare NSC