Provider Demographics
NPI:1619018785
Name:MINIMAL INVASIVE SPINE SPECIALIST
Entity Type:Organization
Organization Name:MINIMAL INVASIVE SPINE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-432-1647
Mailing Address - Street 1:6137 N THESTA ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8605
Mailing Address - Country:US
Mailing Address - Phone:559-432-1647
Mailing Address - Fax:559-436-7828
Practice Address - Street 1:6137 N THESTA ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8605
Practice Address - Country:US
Practice Address - Phone:559-432-1647
Practice Address - Fax:559-436-7828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32342207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C323420Medicare ID - Type Unspecified
CAA87573Medicare UPIN