Provider Demographics
NPI:1750594834
Name:SMITH, MARILYN P (DC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 B AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3421
Mailing Address - Country:US
Mailing Address - Phone:619-435-4175
Mailing Address - Fax:619-435-2995
Practice Address - Street 1:1001 B AVE
Practice Address - Street 2:STE 303
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3421
Practice Address - Country:US
Practice Address - Phone:619-435-4175
Practice Address - Fax:619-435-2995
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC10688111N00000X
AZ3668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC10688AMedicare ID - Type Unspecified
CAT040180Medicare UPIN