Provider Demographics
NPI:1710088752
Name:SMITH, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1100 N PALM CANYON DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4414
Mailing Address - Country:US
Mailing Address - Phone:760-320-9019
Mailing Address - Fax:760-320-9685
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8000
Practice Address - Fax:855-211-3729
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2025-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA00G470110174400000X
CAG470112086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG470110Medicaid
CA00G470110Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAG470110Medicaid