Basic Information
| Provider Information | |||||||||
| NPI: | 1518167857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | CENTRAL CALIFORNIA FACULTY MEDICAL GROUP | ||||||||
| Address2: | 4910 E. CLINTON AVE. SUITE #101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594535258 | ||||||||
| FaxNumber: | 5594535233 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL ED. CHILDREN'S HOSPITAL CENTRAL CALIFORNIA | ||||||||
| Address2: | 9300 VALLEY CHILDREN'S PLACE | ||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593535174 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 20A9510 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.