Provider Demographics
NPI:1194762070
Name:SMITH, EVELYN RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:S
Other - Last Name:LAURITZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:842 CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2902
Mailing Address - Country:US
Mailing Address - Phone:805-542-9678
Mailing Address - Fax:805-547-1626
Practice Address - Street 1:842 CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2902
Practice Address - Country:US
Practice Address - Phone:805-542-9678
Practice Address - Fax:805-542-9685
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD223766207X00000X
CAG77320174400000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT616024300OtherACS/US DEPT LABOR
CAFL915ZOtherMEDICARE PTAN
CA56-2593593OtherCIGNA HEALTHCARE
UT000067751OtherMEDICARE GROUP PTAN
CAG46203Medicare UPIN
UTU00007332Medicare PIN