Provider Demographics
NPI:1780679894
Name:SMITH, DERRICK L (MD)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DERRICK
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-1642
Mailing Address - Country:US
Mailing Address - Phone:877-240-3645
Mailing Address - Fax:951-609-3706
Practice Address - Street 1:1861 W REDLANDS BLVD
Practice Address - Street 2:BUILDING 7B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3119
Practice Address - Country:US
Practice Address - Phone:951-845-8439
Practice Address - Fax:951-769-1038
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A51607Medicare UPIN
CA00G501780Medicare ID - Type Unspecified