Provider Demographics
NPI:1609863018
Name:SMITH, JEFFREY BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRIAN
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 1:22 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1506
Mailing Address - Country:US
Mailing Address - Phone:508-588-6200
Mailing Address - Fax:508-588-6211
Practice Address - Street 1:22 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1506
Practice Address - Country:US
Practice Address - Phone:508-588-6200
Practice Address - Fax:508-588-6211
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1539082080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3175979Medicaid
MA3175979Medicaid