Provider Demographics
NPI:1811981749
Name:SMITH, ROBERT S (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 MAIN ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3618
Mailing Address - Country:US
Mailing Address - Phone:203-373-1775
Mailing Address - Fax:
Practice Address - Street 1:3715 MAIN ST
Practice Address - Street 2:SUITE 306
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3618
Practice Address - Country:US
Practice Address - Phone:203-373-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPOO351213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061364754OtherPRIVATE INSURANCE /TAX ID
CT4800009600OtherRAILROAD MEDICARE ID#
CT030000351CT03OtherBLUE CROSS PROVIDER #
CT4078037Medicaid
CT0004271631OtherAETNA ID#
CT003935OtherHEALTHNET
CT6320755OtherCIGNA ID#
CT6320755OtherCIGNA ID#
CT030000351CT03OtherBLUE CROSS PROVIDER #