Provider Demographics
NPI:1922488154
Name:SMITH, DERRICK JR
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 2ND AVE
Mailing Address - Street 2:APT 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-8307
Mailing Address - Country:US
Mailing Address - Phone:609-556-8345
Mailing Address - Fax:
Practice Address - Street 1:100 2ND AVE
Practice Address - Street 2:APT 2A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8307
Practice Address - Country:US
Practice Address - Phone:609-556-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY603487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered