Provider Demographics
NPI:1588767602
Name:SMITH, MARK ALLAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2500 ALHAMBRA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3156
Mailing Address - Country:US
Mailing Address - Phone:925-427-8585
Mailing Address - Fax:925-427-8591
Practice Address - Street 1:243 GEORGIA STREET
Practice Address - Street 2:STE B
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-556-8100
Practice Address - Fax:707-556-8107
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA72221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29799ZOtherFQHC MEDICARE PART B
CA55-1975OtherFQHC MEDICARE PART A
CAFHC71021FMedicaid
CAFHC70543GMedicaid
CAHAP70543GOtherFPACT
CAHAP71021FOtherFPACT
CA55-1915OtherFQHC MEDICARE PART A
CAZZZ23222ZOtherFQHC MEDICARE PART B