Provider Demographics
NPI:1376106328
Name:SMITH, JUSTIN REYNARD (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:REYNARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 BROADWAY # 1708
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5805
Mailing Address - Country:US
Mailing Address - Phone:646-363-6545
Mailing Address - Fax:
Practice Address - Street 1:1051 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1007
Practice Address - Country:US
Practice Address - Phone:646-363-6545
Practice Address - Fax:850-220-1894
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3119742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry