Healthcare Provider Details

I. General information

NPI: 1235129933
Provider Name (Legal Business Name): ROY A SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 S SALINA ST
SYRACUSE NY
13202-3527
US

IV. Provider business mailing address

819 S SALINA ST
SYRACUSE NY
13202-3527
US

V. Phone/Fax

Practice location:
  • Phone: 315-476-7921
  • Fax:
Mailing address:
  • Phone: 315-476-7921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number138636
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: