Healthcare Provider Details

I. General information

NPI: 1295802700
Provider Name (Legal Business Name): SAMUEL PENNEY SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD STE 1415
LOS ANGELES CA
90017-4005
US

IV. Provider business mailing address

1127 WILSHIRE BLVD STE 1415
LOS ANGELES CA
90017-4005
US

V. Phone/Fax

Practice location:
  • Phone: 213-482-9312
  • Fax:
Mailing address:
  • Phone: 310-864-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA4150
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA41530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: