Provider Demographics
NPI:1407869019
Name:SMITH, DEREK R (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name Type:
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Mailing Address - Street 1:1 TOWNE PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2247
Mailing Address - Country:US
Mailing Address - Phone:860-886-1433
Mailing Address - Fax:860-886-4644
Practice Address - Street 1:ONE TOWNE PARK PLAZA
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-886-1433
Practice Address - Fax:860-886-4644
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT433902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001433903Medicaid
CT001433903Medicaid
F97184Medicare UPIN