Basic Information
| Provider Information | |||||||||
| NPI: | 1104875517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953554201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095241211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1409 E BRIGGSMORE AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095504725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/25/2011 | ||||||||
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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 | 207X00000X | G83519 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | G83519 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G835190 | 05 | CA | MEDICAID |