Healthcare Provider Details

I. General information

NPI: 1780050278
Provider Name (Legal Business Name): CRAIG V. SMITH, M.D., A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 MELROSE AVE.
LOS ANGELES CA
90038
US

IV. Provider business mailing address

6711 MELROSE AVE.
LOS ANGELES CA
90038
US

V. Phone/Fax

Practice location:
  • Phone: 323-307-7220
  • Fax: 213-403-4685
Mailing address:
  • Phone: 323-307-7220
  • Fax: 213-403-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number61164
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number61164
License Number StateCA

VIII. Authorized Official

Name: CRAIG SMITH
Title or Position: CEO
Credential: M.D.
Phone: 323-307-7220