Provider Demographics
NPI:1386024370
Name:SMITH, STACEYANN (MD, MPH)
Entity Type:Individual
Prefix:
First Name:STACEYANN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 KOSSUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2410
Mailing Address - Country:US
Mailing Address - Phone:718-920-5271
Mailing Address - Fax:718-652-5707
Practice Address - Street 1:3444 KOSSUTH AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2410
Practice Address - Country:US
Practice Address - Phone:718-920-5271
Practice Address - Fax:718-652-5707
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209229390200000X
NY294338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program