Provider Demographics
NPI:1356433536
Name:SMOLLER, JEFFREY S (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:SMOLLER
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 HEMPSTEAD AVE STE 244
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4034
Mailing Address - Country:US
Mailing Address - Phone:516-764-3398
Mailing Address - Fax:516-764-3254
Practice Address - Street 1:30 HEMPSTEAD AVE STE 244
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4034
Practice Address - Country:US
Practice Address - Phone:516-764-3398
Practice Address - Fax:516-764-3254
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY155141OtherLICENSE
NY00892860Medicaid
NYA62431Medicare UPIN
NY35D701Medicare ID - Type Unspecified