Provider Demographics
NPI:1336237783
Name:SMITH, STEPHEN PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PETER
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 1:30 HOLMES PL
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1214
Mailing Address - Country:US
Mailing Address - Phone:716-672-6745
Mailing Address - Fax:
Practice Address - Street 1:3898 VINEYARD DR
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-3559
Practice Address - Country:US
Practice Address - Phone:716-363-1515
Practice Address - Fax:716-363-7677
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01534270Medicaid
NY00010265802OtherUNIVERA
NY000523505002OtherBLUECROSS BLUESHIELD WNY
NY0406865OtherINDEPENDENT HEALTH
NY0406865OtherINDEPENDENT HEALTH