Provider Demographics
NPI:1558345488
Name:SMITH, RICHARD MARK (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
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 1:593 EDDY ST
Mailing Address - Street 2:POTTER 3
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:POB 122
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4515
Practice Address - Fax:401-444-7018
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD087042084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRS23723Medicaid
RIRS23723Medicaid
007007266Medicare ID - Type Unspecified