Provider Demographics
NPI:1124107925
Name:SMITH, STEPHEN DOUGLAS (DPM FACFAS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 W ROMNEYA DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1816
Mailing Address - Country:US
Mailing Address - Phone:714-991-3333
Mailing Address - Fax:714-991-6059
Practice Address - Street 1:14641 NEWPORT AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-991-3333
Practice Address - Fax:714-991-6059
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2588213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT36296Medicare UPIN