Provider Demographics
NPI:1043206519
Name:SMITH, J ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 E GENESEE ST
Mailing Address - Street 2:STE A
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2298
Mailing Address - Country:US
Mailing Address - Phone:315-472-4584
Mailing Address - Fax:315-472-4620
Practice Address - Street 1:2200 E GENESEE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2298
Practice Address - Country:US
Practice Address - Phone:315-472-4584
Practice Address - Fax:315-472-4620
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1117791207RH0003X
NY1117792207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00508118Medicaid
NY56623CMedicare ID - Type Unspecified
NY00508118Medicaid
D74922Medicare UPIN