Provider Demographics
NPI: | 1477510873 |
---|---|
Name: | SMITH, DANIEL BRIAN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DANIEL |
Middle Name: | BRIAN |
Last Name: | SMITH |
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: | 285 DAVIDSON AVE |
Mailing Address - Street 2: | SUITE 301 |
Mailing Address - City: | SOMERSET |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08873-4153 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 732-271-1400 |
Mailing Address - Fax: | 732-271-3543 |
Practice Address - Street 1: | 285 DAVIDSON AVE |
Practice Address - Street 2: | SUITE 204 |
Practice Address - City: | SOMERSET |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08873-4153 |
Practice Address - Country: | US |
Practice Address - Phone: | 732-271-1400 |
Practice Address - Fax: | 732-271-3543 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-28 |
Last Update Date: | 2013-05-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | MA0784000 | 207L00000X |
NJ | MA07840000 | 207LP2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 77879 | Medicaid | |
NJ | 01954 | Other | MEDICARE PTAN |
NJ | 77879 | Medicaid |