Provider Demographics
NPI:1649052663
Name:SMARTT, TIMOTHY P
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:P
Last Name:SMARTT
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 1:5947 MEGHAN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-2918
Mailing Address - Country:US
Mailing Address - Phone:916-796-9139
Mailing Address - Fax:
Practice Address - Street 1:5947 MEGHAN WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2918
Practice Address - Country:US
Practice Address - Phone:916-796-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN7268940172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver