Provider Demographics
NPI:1629152897
Name:SMITH, TERRENCE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:EDWARD
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 1:52992 SACRAMENTO STREET
Mailing Address - Street 2:BOX 69
Mailing Address - City:CLARKSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95612-0069
Mailing Address - Country:US
Mailing Address - Phone:916-744-1081
Mailing Address - Fax:
Practice Address - Street 1:52992 SACRAMENTO STREET
Practice Address - Street 2:BOX 69
Practice Address - City:CLARKSBURG
Practice Address - State:CA
Practice Address - Zip Code:95612-0069
Practice Address - Country:US
Practice Address - Phone:916-744-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 42590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G425900Medicaid
CA00G425900Medicare ID - Type Unspecified
CA00G425900Medicaid