Provider Demographics
NPI:1942600044
Name:SMITH, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SMITH
Suffix:
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 1:6504 WALNUT PARK DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1032
Mailing Address - Country:US
Mailing Address - Phone:267-283-5571
Mailing Address - Fax:
Practice Address - Street 1:6504 WALNUT PARK DR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1032
Practice Address - Country:US
Practice Address - Phone:267-283-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program