Provider Demographics
NPI:1588814115
Name:SMITHEDAJKUL, PATRICK Y (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:Y
Last Name:SMITHEDAJKUL
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 1:55 FRUIT ST
Mailing Address - Street 2:WHITE 1003
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-3874
Mailing Address - Fax:617-643-1384
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WHITE 1003
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-3874
Practice Address - Fax:617-643-1384
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP01165791OtherRAILROAD MEDICARE
MNENROLLEDMedicaid