Provider Demographics
NPI:1831229509
Name:SMITH, MICHAEL DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOUGLAS
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 1:6221 WILSHIRE BLVD STE 419
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5224
Mailing Address - Country:US
Mailing Address - Phone:323-932-1654
Mailing Address - Fax:323-932-0460
Practice Address - Street 1:6221 WILSHIRE BLVD STE 419
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5224
Practice Address - Country:US
Practice Address - Phone:323-932-1654
Practice Address - Fax:323-932-0460
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG059151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG59151BMedicare PIN
CAA93530Medicare UPIN