Healthcare Provider Details

I. General information

NPI: 1376568477
Provider Name (Legal Business Name): MARK SMITH AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 E SPRUCE AVE # 130
FRESNO CA
93720-3342
US

IV. Provider business mailing address

1350 E SPRUCE AVE # 130
FRESNO CA
93720-3373
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-5973
  • Fax:
Mailing address:
  • Phone: 559-432-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU2487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: