Individual
DR. JACK DALE SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1321 COTTONWOOD ST, SUITE 302, WOODLAND, CA 95695-5131
(530) 666-1631
Mailing address
3400 DATA DR, RANCHO CORDOVA, CA 95670-7956
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
G37180
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G371800
BLUE SHIELD
CA
05
—
00G371800
—
CA
01
—
P00745248
MEDICARE RAILROAD CARRIER
CA
Enumeration date
06/29/2006
Last updated
05/24/2017
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