Provider Demographics
NPI:1427218833
Name:SMITH, MARISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:251 SALINA MEADOWS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:4900 BROAD ROAD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215
Practice Address - Country:US
Practice Address - Phone:315-492-5437
Practice Address - Fax:315-492-5502
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050185208000000X, 2080S0010X
NY275336208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03378998Medicaid