Healthcare Provider Details

I. General information

NPI: 1912962473
Provider Name (Legal Business Name): CHARLES JOSEPH SMUTNY III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date: 02/22/2011
Reactivation Date: 09/04/2014

III. Provider practice location address

717 LARKFIELD RD
COMMACK NY
11725-2600
US

IV. Provider business mailing address

717 LARKFIELD RD
COMMACK NY
11725-2600
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-4720
  • Fax: 631-486-4722
Mailing address:
  • Phone: 631-486-4720
  • Fax: 631-486-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number206232
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number206232
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number206232
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number206232
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number206232
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number206232
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: