Provider Demographics
NPI:1629119227
Name:SMITH, ROBERT JOSEPH (LPN-NURSE)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPN-NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 FORGHAM RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-3331
Mailing Address - Country:US
Mailing Address - Phone:585-621-5705
Mailing Address - Fax:585-621-5705
Practice Address - Street 1:182 FORGHAM RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3331
Practice Address - Country:US
Practice Address - Phone:585-621-5705
Practice Address - Fax:585-621-5705
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256462-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02042111Medicaid