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1679526784

NPI Code Detail

MEDICARE: ELTON JOHN SMITH M.D.

MEDICARE: ELTON JOHN SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	25MA08836800	NJ
2	2084P0800X	Psychiatry Physician	MD425154	PA
3	2084P0800X	Psychiatry Physician	C1-0008215	DE
4	2084P0804X	Child & Adolescent Psychiatry Physician	0101259244	VA
5	2084P0800X	Psychiatry Physician	036140146	IL
6	2084P0800X	Psychiatry Physician	25MA08836800	NJ
7	2084P0800X	Psychiatry Physician	0101259244	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD425154	OTHER	PA	LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679526784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELTON JOHN SMITH M.D.

Provider Business Mailing Address
First Line	:	4641 E ROOSEVELT BLVD
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19124-2343
Country	:	US
Telephone Number	:	215-831-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 ROOSEVELT BLVD
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19124-2343
Country	:	US
Telephone Number	:	215-831-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	10/27/2025

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Directions to “ ELTON JOHN SMITH M.D.” Practice Location

Language	Start Address	Practice Location

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