Provider Demographics
NPI:1295708675
Name:SMITH, JEROME CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:651 1ST ST W
Mailing Address - Street 2:SUITE H
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7045
Mailing Address - Country:US
Mailing Address - Phone:707-938-3870
Mailing Address - Fax:707-938-3895
Practice Address - Street 1:651 1ST ST W
Practice Address - Street 2:SUITE H
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7045
Practice Address - Country:US
Practice Address - Phone:707-938-3870
Practice Address - Fax:707-938-3895
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME83173208000000X
CAA66490208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC53855FMedicaid
FL262135500Medicaid
FL262135500Medicaid
CAFHC53855FMedicaid