Provider Demographics
NPI:1386677631
Name:SMEGO, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:SMEGO
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 1:1190 5TH AVE
Mailing Address - Street 2:BOX 1028
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6503
Mailing Address - Country:US
Mailing Address - Phone:212-659-6800
Mailing Address - Fax:212-659-6818
Practice Address - Street 1:1190 5TH AVE
Practice Address - Street 2:BOX 1028
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6503
Practice Address - Country:US
Practice Address - Phone:212-659-6800
Practice Address - Fax:212-659-6818
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135757208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01188169Medicaid
B83146Medicare UPIN
5740H1Medicare PIN