Provider Demographics
NPI:1033298906
Name:STREETE SMALLS, SOPHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:
Last Name:STREETE SMALLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11513A MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1851
Mailing Address - Country:US
Mailing Address - Phone:718-558-8998
Mailing Address - Fax:718-558-8999
Practice Address - Street 1:11513A MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1851
Practice Address - Country:US
Practice Address - Phone:718-558-8998
Practice Address - Fax:718-558-8999
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02180096Medicaid
NYG100015967Medicare PIN
H38027Medicare UPIN