Healthcare Provider Details

I. General information

NPI: 1750321717
Provider Name (Legal Business Name): WILLIAM RICHARD SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVE # 100
MODESTO CA
95350-4430
US

IV. Provider business mailing address

1540 FLORIDA AVE # 100
MODESTO CA
95350-4430
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-5557
  • Fax: 209-577-8125
Mailing address:
  • Phone: 209-577-5557
  • Fax: 209-577-8125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC29536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: