Healthcare Provider Details

I. General information

NPI: 1518049212
Provider Name (Legal Business Name): CLARK E SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9820 WILLOW CREEK RD STE 370
SAN DIEGO CA
92131-1112
US

IV. Provider business mailing address

9820 WILLOW CREEK RD STE 370
SAN DIEGO CA
92131-1112
US

V. Phone/Fax

Practice location:
  • Phone: 858-530-9112
  • Fax: 858-530-9118
Mailing address:
  • Phone: 858-530-9112
  • Fax: 858-530-9118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG49105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: