Provider Demographics
NPI: | 1932195542 |
---|---|
Name: | BAYNARD-SMITH, BRENNA ELAINE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | BRENNA |
Middle Name: | ELAINE |
Last Name: | BAYNARD-SMITH |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | DR |
Other - First Name: | BRENNA |
Other - Middle Name: | BAYNARD |
Other - Last Name: | SMITH |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 500 S 7TH AVE STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | BARSTOW |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92311-3057 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 760-255-2400 |
Mailing Address - Fax: | 760-255-4646 |
Practice Address - Street 1: | 500 S 7TH AVE STE A |
Practice Address - Street 2: | |
Practice Address - City: | BARSTOW |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92311-3057 |
Practice Address - Country: | US |
Practice Address - Phone: | 760-255-2400 |
Practice Address - Fax: | 760-255-4646 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-09-20 |
Last Update Date: | 2021-10-01 |
Deactivation Date: | 2006-03-23 |
Deactivation Code: | |
Reactivation Date: | 2006-04-18 |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G65654 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 1164567426 | Other | NPI GROUP II |
CA | 330927078 | Other | TAX ID |
CA | ZZZ07612Z | Medicare PIN | |
CA | E80534 | Medicare UPIN |