Basic Information
| Provider Information | |||||||||
| NPI: | 1376599191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843418 | ||||||||
| FaxNumber: | 4158838082 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 EL CAMINO REAL STE 100 | ||||||||
| Address2: | |||||||||
| City: | ATHERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940273803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503643080 | ||||||||
| FaxNumber: | 6503642004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A68606 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 08255024 | 05 | CO | MEDICAID | 300134148 | 01 | WA | RAILROAD MEDICARE | OTHER | 5578SM | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8905618 | 01 | WA | L&I; CVCP | OTHER | 1376599191 | 05 | NV | MEDICAID | 300134150 | 01 | CA | RAILROAD MEDICARE | OTHER | 912841 | 05 | AZ | MEDICAID | 00A686060 | 05 | CA | MEDICAID | 9413833 | 05 | WA | MEDICAID | 0212626 | 01 | WA | L&I | OTHER |