Provider Demographics
NPI:1235129933
Name:SMITH, ROY A (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3527
Mailing Address - Country:US
Mailing Address - Phone:315-476-7921
Mailing Address - Fax:
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3527
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138636207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00831732Medicaid
NYRB2179Medicare PIN
NY00831732Medicaid
NY395030Medicare ID - Type Unspecified