Healthcare Provider Details

I. General information

NPI: 1093903890
Provider Name (Legal Business Name): LLOYD D. SMITH JR., M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 TULLY RD #7
MODESTO CA
95350-4082
US

IV. Provider business mailing address

PO BOX 576188
MODESTO CA
95357-6188
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-2748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number0G9623
License Number StateCA

VIII. Authorized Official

Name: LLOYD SMITH
Title or Position: OWNER
Credential:
Phone: 209-521-2748