Healthcare Provider Details

I. General information

NPI: 1700057262
Provider Name (Legal Business Name): PETER SMITH, DPM, FACFAO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HALLOCK RD SUITE 4
STONY BROOK NY
11790-3033
US

IV. Provider business mailing address

207 HALLOCK RD SUITE 4
STONY BROOK NY
11790-3033
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-2300
  • Fax: 631-689-2078
Mailing address:
  • Phone: 631-689-2300
  • Fax: 631-689-2078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3922830001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number3922830001
License Number StateNY

VIII. Authorized Official

Name: DR. PETER SMITH
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 631-689-2300