Provider Demographics
NPI:1427374941
Name:SMITH, COLIN
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 WALNUT ST
Mailing Address - Street 2:APT. 302
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5437
Mailing Address - Country:US
Mailing Address - Phone:267-997-1074
Mailing Address - Fax:
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:480 MAIN BLDG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-955-3947
Practice Address - Fax:215-955-5245
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD456930207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program