Provider Demographics
NPI:1790148385
Name:SMITH, CANDACE YVETTE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:YVETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:SLU DIVISION OF EMERGENCY MEDICINE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-268-7133
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:SLU DIVISION OF EMERGENCY MEDICINE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-268-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82603207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine