Provider Demographics
NPI:1992833875
Name:SMITH, BEVERLY D (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:D
Last Name:SMITH
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:PO BOX 221114
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-8114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2319
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2517172084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry