Healthcare Provider Details

I. General information

NPI: 1063480473
Provider Name (Legal Business Name): PAUL LAWRENCE SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD 990W
SANTA MONICA CA
90404-2103
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD 990W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-4484
  • Fax: 310-829-4481
Mailing address:
  • Phone: 310-829-4484
  • Fax: 310-829-4481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA21571
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA21571
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA21571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: