Healthcare Provider Details

I. General information

NPI: 1609295187
Provider Name (Legal Business Name): JUSTIN KERRY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

IV. Provider business mailing address

PO BOX 630
FRANKLIN LAKES NJ
07417-0630
US

V. Phone/Fax

Practice location:
  • Phone: 201-847-9320
  • Fax: 201-847-0059
Mailing address:
  • Phone: 201-847-9320
  • Fax: 201-847-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA10297300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: