Healthcare Provider Details

I. General information

NPI: 1013954130
Provider Name (Legal Business Name): GREGORY ALAN SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 N FRESNO ST STE 105
FRESNO CA
93710-8331
US

IV. Provider business mailing address

PO BOX 3854
REDONDO BEACH CA
90277-1717
US

V. Phone/Fax

Practice location:
  • Phone: 559-374-5130
  • Fax: 888-977-4918
Mailing address:
  • Phone: 310-863-0690
  • Fax: 310-492-9941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberA50680
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA50680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: