Healthcare Provider Details

I. General information

NPI: 1295708675
Provider Name (Legal Business Name): JEROME CHARLES SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 1ST ST W SUITE H
SONOMA CA
95476-7045
US

IV. Provider business mailing address

651 1ST ST W SUITE H
SONOMA CA
95476-7045
US

V. Phone/Fax

Practice location:
  • Phone: 707-938-3870
  • Fax: 707-938-3895
Mailing address:
  • Phone: 707-938-3870
  • Fax: 707-938-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME83173
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA66490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: