Provider Demographics
NPI:1619459385
Name:SMITH, ANDREW JAY (AOS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:AOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 RUTLAND RD APT 2L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5577
Mailing Address - Country:US
Mailing Address - Phone:917-770-0650
Mailing Address - Fax:
Practice Address - Street 1:369 RUTLAND RD APT 2L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5577
Practice Address - Country:US
Practice Address - Phone:917-770-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025717-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist