MEDICARE: DR. DAN SULLIVAN 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	208200000X	Plastic Surgery Physician	CFE 25635	CA

General Provider Information

NPI Number	:	1548530454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAN SULLIVAN SMITH M.D.

Provider Business Mailing Address
First Line	:	5988 SAINT DENIS TER
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5988 SAINT DENIS TER
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3015
Country	:	US
Telephone Number	:	619-287-8049
Fax Number	:	619-287-8044

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

Provider Enumeration Date	:	01/09/2012
Last Update Date	:	01/09/2012

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