Provider Demographics
NPI:1982686929
Name:SMITH, BRIAN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RICHARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:YNHH, CLINIC BUILDING 407
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-2286
Mailing Address - Fax:203-688-4111
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH, CLINIC BUILDING 407
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2286
Practice Address - Fax:203-688-4111
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029372207RH0000X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001293729Medicaid
D94065Medicare UPIN
CT440000031Medicare ID - Type Unspecified