Provider Demographics
NPI:1912096579
Name:SMITH, GLEN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:G
Other - Middle Name:SCOTT
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2501 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3204
Mailing Address - Country:US
Mailing Address - Phone:714-633-1011
Mailing Address - Fax:714-633-4883
Practice Address - Street 1:2501 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3204
Practice Address - Country:US
Practice Address - Phone:714-633-1011
Practice Address - Fax:714-633-4883
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG42987BMedicare ID - Type Unspecified
CAA49187Medicare UPIN