Provider Demographics
NPI:1326425000
Name:SMITH, LISA MAE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 BROADWAY UNIT 617
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2623
Mailing Address - Country:US
Mailing Address - Phone:631-805-8399
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY HOSPITAL DEPARTMENT OF PEDIATRIC
Practice Address - Street 2:HSC T-11 / 040
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8111
Practice Address - Country:US
Practice Address - Phone:631-444-2020
Practice Address - Fax:631-444-2894
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61324744208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program