Provider Demographics
NPI:1720195209
Name:SMALL, MARTHA Y (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:Y
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CORPORATE DIVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-452-8322
Mailing Address - Fax:203-452-2296
Practice Address - Street 1:4699 MAIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1830
Practice Address - Country:US
Practice Address - Phone:203-452-8322
Practice Address - Fax:203-452-2296
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028062208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001280627Medicaid
CT001280627Medicaid