Provider Demographics
NPI:1023314143
Name:SMITH, JOHNELLE R (MD)
Entity type:Individual
Prefix:
First Name:JOHNELLE
Middle Name:R
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 1:1180 BEACON ST
Mailing Address - Street 2:STE 3C
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3806
Mailing Address - Country:US
Mailing Address - Phone:617-202-9222
Mailing Address - Fax:617-879-0933
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:STE 3C
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3806
Practice Address - Country:US
Practice Address - Phone:617-202-9222
Practice Address - Fax:617-879-0933
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078591208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation