Provider Demographics
NPI:1912962473
Name:SMUTNY, CHARLES JOSEPH III (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:SMUTNY
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 LARKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2600
Mailing Address - Country:US
Mailing Address - Phone:631-486-4720
Mailing Address - Fax:631-486-4722
Practice Address - Street 1:717 LARKFIELD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2600
Practice Address - Country:US
Practice Address - Phone:631-486-4720
Practice Address - Fax:631-486-4722
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2014-09-04
Deactivation Date:2011-02-22
Deactivation Code:
Reactivation Date:2014-09-04
Provider Licenses
StateLicense IDTaxonomies
NY206232133NN1002X, 171100000X, 204C00000X, 204D00000X, 208D00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171100000XOther Service ProvidersAcupuncturist
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1912962473OtherINDIVIDUAL NPI
NYWEN311OtherMEDICARE GROUP PIN
NY01V30EN311OtherMEDICARE INTERUM INDIVPIN
NY1639358799OtherGROUP NPI
NY206232OtherNY STATE LICENSE #
NY01V30EN311OtherMEDICARE PTAN
NY62296658OtherINDIVIDUAL MEDICARE PIN
NY01V30EN311OtherMEDICARE PTAN
NYWEN311OtherMEDICARE GROUP PIN