Healthcare Provider Details

I. General information

NPI: 1225664964
Provider Name (Legal Business Name): ANDRES SMITH M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7227 BROADWAY STE 405
LEMON GROVE CA
91945-1505
US

IV. Provider business mailing address

7227 BROADWAY STE 405
LEMON GROVE CA
91945-1505
US

V. Phone/Fax

Practice location:
  • Phone: 619-253-6451
  • Fax:
Mailing address:
  • Phone: 619-253-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANDRES SMITH
Title or Position: PRESIDENT
Credential: MD
Phone: 619-737-7511