=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417131871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY A SMITH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2007
-----------------------------------------------------
Last Update Date | 12/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 4TH ST STE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-526-4777
-----------------------------------------------------
Fax | 707-526-8809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1041 4TH ST STE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-526-4777
-----------------------------------------------------
Fax | 707-526-8809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LARRY A SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-526-4777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E21510
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------