Provider Demographics
NPI:1780211383
Name:SMITH, JIBRIL AHMAD (MD)
Entity Type:Individual
Prefix:
First Name:JIBRIL
Middle Name:AHMAD
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 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:HARTFORD HEALTHCARE-CVO
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1601
Practice Address - Country:US
Practice Address - Phone:203-324-5740
Practice Address - Fax:203-324-5735
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74327207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine