Healthcare Provider Details

I. General information

NPI: 1629152897
Provider Name (Legal Business Name): TERRENCE EDWARD SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52992 SACRAMENTO STREET BOX 69
CLARKSBURG CA
95612-0069
US

IV. Provider business mailing address

52992 SACRAMENTO STREET BOX 69
CLARKSBURG CA
95612-0069
US

V. Phone/Fax

Practice location:
  • Phone: 916-744-1081
  • Fax:
Mailing address:
  • Phone: 916-744-1081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG 42590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: