Provider Demographics
NPI:1801857453
Name:SMITH, RICHARD CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
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 1:1350 W 6TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3544
Mailing Address - Country:US
Mailing Address - Phone:310-833-2428
Mailing Address - Fax:310-833-7850
Practice Address - Street 1:1350 W 6TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3544
Practice Address - Country:US
Practice Address - Phone:310-833-2428
Practice Address - Fax:310-833-7850
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31822207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7993517Medicaid
CA1720126089OtherFACILITY NPI
CAC31820OtherLICENSE
CAWC31822BOtherMEDICARE PPIN
CA00C318220Medicaid
CAA34720Medicare UPIN
CA00C318220Medicaid