Provider Demographics
NPI:1912968306
Name:SMITH, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3026
Mailing Address - Country:US
Mailing Address - Phone:201-339-2300
Mailing Address - Fax:201-339-9922
Practice Address - Street 1:946 AVENUE C
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3026
Practice Address - Country:US
Practice Address - Phone:201-339-2300
Practice Address - Fax:201-339-9922
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA66625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4751701Medicaid
NJ032805Medicare PIN
H06061Medicare UPIN
NJ4751701Medicaid