Provider Demographics
NPI:1649064593
Name:SMITH, CONNOR MATTINGLY (RRA)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:MATTINGLY
Last Name:SMITH
Suffix:
Gender:
Credentials:RRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MEADOWOODS LN APT 6
Mailing Address - Street 2:
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-2002
Mailing Address - Country:US
Mailing Address - Phone:518-960-0209
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-654-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000269243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant