Provider Demographics
NPI:1942414511
Name:SMITH, VANCE LA BARON (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:LA BARON
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 1:300 BERRY ST
Mailing Address - Street 2:UNIT 817
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-1593
Mailing Address - Country:US
Mailing Address - Phone:614-313-3444
Mailing Address - Fax:
Practice Address - Street 1:300 BERRY ST
Practice Address - Street 2:UNIT 817
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-1593
Practice Address - Country:US
Practice Address - Phone:614-313-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111926208600000X
OH57-007911208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEA834AMedicaid
COCOAAA1467Medicaid