Provider Demographics
NPI:1508877077
Name:SMITH, PHILLIP FRANK SR (DPM)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:FRANK
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2110 DORCHESTER AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5628
Mailing Address - Country:US
Mailing Address - Phone:617-298-5277
Mailing Address - Fax:617-298-3830
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-298-5277
Practice Address - Fax:617-298-3830
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1363213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0396117Medicaid
MAY70441Medicare ID - Type Unspecified
MA0396117Medicaid