Provider Demographics
NPI:1710071063
Name:SMITH, GARY C (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
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 1:45 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-3207
Mailing Address - Country:US
Mailing Address - Phone:585-343-3688
Mailing Address - Fax:585-343-5076
Practice Address - Street 1:45 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-3207
Practice Address - Country:US
Practice Address - Phone:585-343-3688
Practice Address - Fax:585-343-5076
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00463149Medicaid
NY102142BJOtherPREFERRED CARE
000504122001OtherBLUE CROSS WNY
NYP0101039681OtherBLUE CHOICE
161589189OtherTAX ID
00010168501OtherUNIVERA
NY000504122001OtherCOMMUNITY BLUE
0403839OtherIHA
NYCC9545Medicare PIN
NYP0101039681OtherBLUE CHOICE
161589189OtherTAX ID