Healthcare Provider Details

I. General information

NPI: 1730307026
Provider Name (Legal Business Name): PHYLLIS J SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 ELM ST
HUNTINGTON NY
11743-3402
US

IV. Provider business mailing address

28 ELM ST
HUNTINGTON NY
11743-3402
US

V. Phone/Fax

Practice location:
  • Phone: 631-421-4398
  • Fax: 631-421-1914
Mailing address:
  • Phone: 631-421-4398
  • Fax: 631-421-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number152208
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: