Provider Demographics
NPI:1700057262
Name:PETER SMITH, DPM, FACFAO, PC
Entity Type:Organization
Organization Name:PETER SMITH, DPM, FACFAO, PC
Other - Org Name:PETER SMITH, DPM, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-689-2300
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-689-2300
Mailing Address - Fax:631-689-2078
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-689-2300
Practice Address - Fax:631-689-2078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3922830001332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3922830001Medicare NSC