Provider Demographics
NPI:1104875814
Name:SMITH, STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
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:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-0054
Mailing Address - Country:US
Mailing Address - Phone:973-980-0195
Mailing Address - Fax:973-774-1920
Practice Address - Street 1:189 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:NJ
Practice Address - Zip Code:07068-1347
Practice Address - Country:US
Practice Address - Phone:973-980-0195
Practice Address - Fax:973-774-1920
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06023600207RI0200X
NJMA060236207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8420301Medicaid
NJG30983Medicare UPIN
NJ884479Medicare ID - Type Unspecified