MEDICARE: DR. SAMUEL PENNEY SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	A41530	CA
2	2084P0800X	Psychiatry Physician	A4150	CA

General Provider Information

NPI Number	:	1295802700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL PENNEY SMITH M.D.

Provider Business Mailing Address
First Line	:	1127 WILSHIRE BLVD STE 1415
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4005
Country	:	US
Telephone Number	:	310-864-0377
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 WILSHIRE BLVD STE 1415
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4005
Country	:	US
Telephone Number	:	213-482-9312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	06/05/2023

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