=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740546209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN ROBERT SMALL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2012
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S HICKORY ST STE 114
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025-4360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-905-9410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 S HICKORY ST STE 114
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025-4360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-905-9410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A120383
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083A0300X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | A120383
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A120383
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------