Provider Demographics
NPI:1740519883
Name:DR. JEFFREY SMALL
Entity type:Organization
Organization Name:DR. JEFFREY SMALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-372-4419
Mailing Address - Street 1:4695 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1802
Mailing Address - Country:US
Mailing Address - Phone:203-372-4419
Mailing Address - Fax:203-372-4919
Practice Address - Street 1:4695 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1802
Practice Address - Country:US
Practice Address - Phone:203-372-4419
Practice Address - Fax:203-372-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTBS3578397174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT125947OtherWELLCARE
ZS278OtherOXFORD
003985OtherHEALTHNET
CT001304956Medicaid
4337423OtherAETNA
01030495CT03OtherANTHEM BLUE CROSS & BLUE SHIELD
CT001304956Medicaid