Healthcare Provider Details

I. General information

NPI: 1366537904
Provider Name (Legal Business Name): JOHN D. SMOOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVENUE, SUITE 130
LA JOLLA CA
92037
US

IV. Provider business mailing address

9850 GENESEE AVENUE, SUITE 130
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 858-452-1981
  • Fax: 858-452-9910
Mailing address:
  • Phone: 858-452-1981
  • Fax: 858-452-9910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG62141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: