Provider Demographics
NPI:1356313787
Name:SMITH, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
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:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-0599
Mailing Address - Country:US
Mailing Address - Phone:518-643-7037
Mailing Address - Fax:518-643-2125
Practice Address - Street 1:9 ELM ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-2812
Practice Address - Country:US
Practice Address - Phone:518-643-7037
Practice Address - Fax:518-643-2125
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1902181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01354865Medicaid
NYE15363Medicare UPIN
NY01354865Medicaid