Provider Demographics
NPI:1124143334
Name:SMITH, CARL W (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12598 CENTRAL AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3502
Mailing Address - Country:US
Mailing Address - Phone:909-628-6556
Mailing Address - Fax:909-628-3831
Practice Address - Street 1:12598 CENTRAL AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3502
Practice Address - Country:US
Practice Address - Phone:909-628-6556
Practice Address - Fax:909-628-3831
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48139Medicare UPIN
CA00G402060Medicare PIN