Provider Demographics
NPI:1023786746
Name:SMITH, WILLIE
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
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 1:1265 N CAPITOL AVE APT 90
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2546
Mailing Address - Country:US
Mailing Address - Phone:408-886-8070
Mailing Address - Fax:
Practice Address - Street 1:1265 N CAPITOL AVE APT 90
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-2546
Practice Address - Country:US
Practice Address - Phone:408-886-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4709810172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver