Healthcare Provider Details

I. General information

NPI: 1417584939
Provider Name (Legal Business Name): WILSON T SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

IV. Provider business mailing address

5820 OWENS DR BLDG E2ND
PLEASANTON CA
94588-3900
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-4000
  • Fax:
Mailing address:
  • Phone: 916-784-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA190061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: