Provider Demographics
NPI:1881714319
Name:SMITH, DOREEN (MD)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
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 PINE KNOB DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5218
Mailing Address - Country:US
Mailing Address - Phone:518-937-3073
Mailing Address - Fax:
Practice Address - Street 1:165 PLANK RD
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12051-2617
Practice Address - Country:US
Practice Address - Phone:518-731-2741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10010842OtherCDPHP
NY78O623OtherBLUE CROSS
NY10010842OtherCDPHP
NY78O623OtherBLUE CROSS