Provider Demographics
NPI:1851831952
Name:SMUCKLER, JEREMY (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:SMUCKLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2506
Mailing Address - Country:US
Mailing Address - Phone:516-326-4580
Mailing Address - Fax:516-326-0793
Practice Address - Street 1:1730 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2506
Practice Address - Country:US
Practice Address - Phone:516-326-4580
Practice Address - Fax:516-326-0793
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041052-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist