Provider Demographics
NPI:1952344673
Name:SMIRLOCK, STEPHEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:SMIRLOCK
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 1:136A SUNFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2461
Mailing Address - Country:US
Mailing Address - Phone:917-747-1749
Mailing Address - Fax:718-724-1889
Practice Address - Street 1:1000 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4402
Practice Address - Country:US
Practice Address - Phone:917-747-1749
Practice Address - Fax:718-724-1889
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00166100213ES0131X
NYN0022322213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8828369Medicaid
NY00413369Medicaid
NJ8828369Medicaid
NYT50697Medicare UPIN
NY0218560003Medicare NSC
NY00413369Medicaid
NY1517950001Medicare NSC
NY02832Medicare PIN