Provider Demographics
NPI:1922018357
Name:SMALL, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-659-4050
Mailing Address - Fax:631-659-4099
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-659-4050
Practice Address - Fax:631-659-4099
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178990-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2C4865OtherHEALTHNET
NYCS493OtherOXFORD
NY01464039Medicaid
NY0400986OtherGHI
NY92K881OtherBLUE CROSS/ BLUE SHIELD
NY01464039Medicaid
NYCS493OtherOXFORD