Provider Demographics
NPI:1275908972
Name:SMITH, JAMES W
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 COMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718
Mailing Address - Country:US
Mailing Address - Phone:732-708-1661
Mailing Address - Fax:
Practice Address - Street 1:40 COMPTON ST
Practice Address - Street 2:
Practice Address - City:BELFORD
Practice Address - State:NJ
Practice Address - Zip Code:07718-1508
Practice Address - Country:US
Practice Address - Phone:732-708-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNJMedicaid