Provider Demographics
NPI:1528181781
Name:SMITH, MICHAEL LARRY (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LARRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CRAIG RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8787
Mailing Address - Country:US
Mailing Address - Phone:732-780-2332
Mailing Address - Fax:732-780-4323
Practice Address - Street 1:100 CRAIG RD
Practice Address - Street 2:SUITE 206
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8787
Practice Address - Country:US
Practice Address - Phone:732-780-2332
Practice Address - Fax:732-780-4323
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ2716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJSM520249Medicare ID - Type Unspecified