Provider Demographics
NPI:1083862932
Name:DAVID SMITH MD
Entity type:Organization
Organization Name:DAVID SMITH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:VIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CCS-P
Authorized Official - Phone:518-563-8290
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:9 ELM STREET
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-0599
Mailing Address - Country:US
Mailing Address - Phone:518-643-7037
Mailing Address - Fax:518-643-2125
Practice Address - Street 1:9 ELM ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-2812
Practice Address - Country:US
Practice Address - Phone:518-643-7037
Practice Address - Fax:518-643-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190218208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01354865Medicaid
NY01354865Medicaid