Provider Demographics
NPI:1790116374
Name:JACQUELINE SMITH, MD PC
Entity Type:Organization
Organization Name:JACQUELINE SMITH, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-928-3341
Mailing Address - Street 1:716 BROAD STREET
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1607
Mailing Address - Country:US
Mailing Address - Phone:973-221-3122
Mailing Address - Fax:973-710-0620
Practice Address - Street 1:716 BROAD ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1645
Practice Address - Country:US
Practice Address - Phone:973-221-3122
Practice Address - Fax:973-710-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09182300207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0310981Medicaid