Healthcare Provider Details

I. General information

NPI: 1881642999
Provider Name (Legal Business Name): RONALD DAVID SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 WILLIS ST
BRISTOL CT
06010-7267
US

IV. Provider business mailing address

574 WILLIS ST
BRISTOL CT
06010-7267
US

V. Phone/Fax

Practice location:
  • Phone: 959-217-1500
  • Fax: 959-217-1500
Mailing address:
  • Phone: 959-217-1500
  • Fax: 959-217-1500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number202000
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number5689
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number11778
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number200100466
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number202000
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number200100466
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: