Provider Demographics
NPI:1285467662
Name:SMITH, MASON RILEY
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:RILEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1002
Mailing Address - Country:US
Mailing Address - Phone:315-635-5000
Mailing Address - Fax:315-622-1110
Practice Address - Street 1:6265 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8751
Practice Address - Country:US
Practice Address - Phone:315-635-5000
Practice Address - Fax:315-458-2975
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist