=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548259385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN P SMITH MD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2005
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14911 NATIONAL AVE STE 1
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-2632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-358-3448
-----------------------------------------------------
Fax | 408-356-4628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1530 MONTEVAL PL
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95120-5714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-406-1895
-----------------------------------------------------
Fax | 408-268-7814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN PHILIP SMITH III
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-406-1895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------