Provider Demographics
NPI:1598777542
Name:SMITH, MARILYN P (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CAMBRIDGE DR
Mailing Address - Street 2:CREDENTIALS XPRESS
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 MONROE TPKE
Practice Address - Street 2:CANTERBURY PEDIATRICS
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2276
Practice Address - Country:US
Practice Address - Phone:203-452-1063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030831208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001308312Medicaid
CT010030831CT04OtherANTHEM BC/BS
CT36-4505937OtherNEHCA HMC/PPO
CT36-4505937OtherCOMMUNITY HEALTH NETWORK
CT2V2847OtherHEALTH NET
CT36-4505937OtherMULTIPLAN
CT507Y41OtherEMPIRE BC/BS
CT36-4505937OtherUNITED HEALTHCARE
CT36-4505937OtherFIRST HEALTH
CT308310OtherCONNECTICARE
CT36-4505937OtherGREAT WEST HEALTHCARE
CT36-4505937OtherNORTHEAST HEALTH DIRECT
CT36-4505937OtherPIONEER HEALTH NETWORK
CT2999672OtherAETNA
CT36-4505937OtherPRIVATE HEALTHCARE SYSTEM
CT36-4505937OtherPOMCO
CT36-4505937OtherCONSUMER HEALTH NETWORK
CT36-4505937OtherNATIONAL PROVIDER NETWORK
CT4398415006OtherCIGNA
CTZP164OtherOXFORD HEALTH PLANS