Provider Demographics
NPI:1609813468
Name:SMITH, EDWARD FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:FRED
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 1:11 PLAZA ST W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3706
Mailing Address - Country:US
Mailing Address - Phone:718-638-2020
Mailing Address - Fax:
Practice Address - Street 1:11 PLAZA ST W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3706
Practice Address - Country:US
Practice Address - Phone:718-638-2020
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168677-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01132970Medicaid
NY01132970Medicaid
NYA62021Medicare UPIN