Healthcare Provider Details

I. General information

NPI: 1013594076
Provider Name (Legal Business Name): NATHAN W SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

25 WILLIAMS BLVD APT 2F
LAKE GROVE NY
11755-3519
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 804-387-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number333910-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: