Basic Information
| Provider Information | |||||||||
| NPI: | 1255489159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DELANEY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E WALNUT AVE | ||||||||
| Address2: | #250 | ||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902452605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103012030 | ||||||||
| FaxNumber: | 3103065247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900153010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103012030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 10/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | G40381 | CA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G403810 | 05 | CA | MEDICAID |