Provider Demographics
NPI:1760830285
Name:SMITH, NATHANAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:NATHANAEL
Middle Name:
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 1:1440 N CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2677
Mailing Address - Country:US
Mailing Address - Phone:626-258-7487
Mailing Address - Fax:
Practice Address - Street 1:5220 CLARK AVE STE 125
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2623
Practice Address - Country:US
Practice Address - Phone:562-804-1381
Practice Address - Fax:562-925-8898
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5486213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty