Provider Demographics
NPI:1730671611
Name:SMITH, JUSTIN MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 PACIFIC AVE # 8
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-6713
Mailing Address - Country:US
Mailing Address - Phone:609-441-8127
Mailing Address - Fax:
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-441-8127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2021-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB11208000207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program