Provider Demographics
NPI:1710088752
Name:SMITH, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
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 1:1100 N PALM CANYON DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4414
Mailing Address - Country:US
Mailing Address - Phone:760-320-9019
Mailing Address - Fax:760-320-9685
Practice Address - Street 1:1100 N PALM CANYON DR
Practice Address - Street 2:SUITE 211
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4414
Practice Address - Country:US
Practice Address - Phone:760-320-9019
Practice Address - Fax:760-320-9685
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G470110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG470110Medicaid
CA00G470110Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAG470110Medicaid