Provider Demographics
NPI:1932256815
Name:SMITH, JESSE JOSHUA (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JOSHUA
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 YORK AVE
Mailing Address - Street 2:H-1206
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:212-639-7537
Mailing Address - Fax:212-717-3169
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:H-1206
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-7537
Practice Address - Fax:212-717-3169
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY268216-1208600000X
TNMD0000041437208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program