Provider Demographics
NPI:1518923119
Name:SMITH, STEPHEN P JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:SMITH
Suffix:JR
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 1:725 BUCKLES CT N STE 210
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6884
Mailing Address - Country:US
Mailing Address - Phone:614-245-4263
Mailing Address - Fax:614-245-4269
Practice Address - Street 1:725 BUCKLES CT N STE 210
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-245-4263
Practice Address - Fax:614-245-4269
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081746207Y00000X
NY239521207Y00000X
OH35-081746207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2387019Medicaid
OH2599942Medicaid
OH2599942Medicaid
OH2387019Medicaid
OH4211991Medicare PIN