Provider Demographics
NPI:1093212441
Name:SMITH, KYLE MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
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 1:340 HOWELLS RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5322
Mailing Address - Country:US
Mailing Address - Phone:631-666-1956
Mailing Address - Fax:631-666-1957
Practice Address - Street 1:340 HOWELLS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5322
Practice Address - Country:US
Practice Address - Phone:631-666-1956
Practice Address - Fax:631-666-1957
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NY308861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty