Provider Demographics
NPI:1821099458
Name:SMITH, MARK V (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:V
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 1:86 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2389
Mailing Address - Country:US
Mailing Address - Phone:315-792-7629
Mailing Address - Fax:315-792-3617
Practice Address - Street 1:86 GENESEE ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2389
Practice Address - Country:US
Practice Address - Phone:315-792-7629
Practice Address - Fax:315-792-3617
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178548208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463538Medicaid
NYJ400072727Medicare UPIN
NY01463538Medicaid
F58730Medicare UPIN