Healthcare Provider Details

I. General information

NPI: 1669887899
Provider Name (Legal Business Name): ELLYN ALLYSE SMITH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 12/30/2024
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W STE 1600
ORANGE CA
92868-5903
US

IV. Provider business mailing address

185 ROSEBERRY ST FARLEY BLDG 2ND FLOOR
PHILLIPSBURG NJ
08865-1690
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8598
  • Fax:
Mailing address:
  • Phone: 908-847-2621
  • Fax: 908-847-3045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT206685
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA160672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: