Provider Demographics
NPI:1679600811
Name:SMITH, GARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
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 1:2 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3043
Mailing Address - Country:US
Mailing Address - Phone:916-782-7778
Mailing Address - Fax:916-786-6243
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3043
Practice Address - Country:US
Practice Address - Phone:916-782-7778
Practice Address - Fax:916-786-6243
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A247851Medicaid
CA00A247851Medicaid
CA00A247851Medicaid
AS4445145OtherDEA #