Healthcare Provider Details

I. General information

NPI: 1104875814
Provider Name (Legal Business Name): STEPHEN SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 EAGLE ROCK AVE
ROSELAND NJ
07068-1347
US

IV. Provider business mailing address

PO BOX 54
ROSELAND NJ
07068-0054
US

V. Phone/Fax

Practice location:
  • Phone: 973-980-0195
  • Fax: 973-774-1920
Mailing address:
  • Phone: 973-980-0195
  • Fax: 973-774-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMA06023600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMA060236
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: