=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497395685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN D. SMITH MD CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 01/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27882 FORBES RD STE 203
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-1267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-347-2400
-----------------------------------------------------
Fax | 949-347-2424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 N. TUSTIN AVE
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-347-1000
-----------------------------------------------------
Fax | 714-647-1245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | BRIAN D. SMITH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-347-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------