Provider Demographics
NPI:1043389869
Name:SMITH, JOHN P (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BROADWAY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FAIRLAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-794-6505
Mailing Address - Fax:201-794-1167
Practice Address - Street 1:1501 BROADWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:FAIRLAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-794-6505
Practice Address - Fax:201-794-1167
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ029040207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0465607Medicaid
SM45780ZMedicare ID - Type Unspecified
NJ0465607Medicaid