Provider Demographics
NPI:1851361414
Name:SMITH, PETER (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-689-2300
Mailing Address - Fax:631-689-2078
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-689-2300
Practice Address - Fax:631-689-2078
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004433213E00000X
MAPD1905213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1911509OtherOXFORD
NY01895183Medicaid
NYPO 44330OtherWORKERS COMPENSATION
NYNYB002451OtherSUBMITTER ID
NY6364966004OtherCIGNA
NY10259OtherVYTRA
NY10259OtherVYTRA
NYP1911509OtherOXFORD
NYPB3441Medicare PIN