Provider Demographics
NPI:1699729475
Name:SMITH, DOROTHEA (NP)
Entity type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1304
Mailing Address - Country:US
Mailing Address - Phone:203-688-5555
Mailing Address - Fax:203-688-7274
Practice Address - Street 1:2 CHURCH ST.
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:203-787-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002890363L00000X
CT2890363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500001470OtherMEDICARE OTHER
CT004249696Medicaid
CTP30475Medicare UPIN