Provider Demographics
NPI:1245518448
Name:SMITH, AUSTIN THOMAS (IDC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 GEMINI AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4861
Mailing Address - Country:US
Mailing Address - Phone:760-812-0946
Mailing Address - Fax:
Practice Address - Street 1:9414 GEMINI AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4861
Practice Address - Country:US
Practice Address - Phone:760-812-0946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman