Provider Demographics
NPI:1851484554
Name:SMITH, GORDON H
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:H
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 NORRIS CANYON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5406
Mailing Address - Country:US
Mailing Address - Phone:925-277-1135
Mailing Address - Fax:925-277-0457
Practice Address - Street 1:5401 NORRIS CANYON RD STE 206
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5406
Practice Address - Country:US
Practice Address - Phone:925-277-1135
Practice Address - Fax:925-277-0457
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20008207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40814Medicare UPIN