Provider Demographics
NPI:1215993993
Name:SMITH, RICHARD D (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
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 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-963-6390
Mailing Address - Fax:860-963-6343
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-963-6390
Practice Address - Fax:860-963-6343
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD7534208000000X
CT045662208000000X
MAXS49444486207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7001347Medicaid
A72514Medicare UPIN
RI007001347Medicare ID - Type Unspecified