1427094259 NPI number — DR. MAASI JACOB SMITH DPM

Table of content: DR. MAASI JACOB SMITH DPM (NPI 1427094259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427094259 NPI number — DR. MAASI JACOB SMITH DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MAASI
Provider Middle Name:
JACOB
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427094259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWEDESBORO
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08085-2579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-665-9225
Provider Business Mailing Address Fax Number:
215-665-9242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 BALA AVE STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-665-9225
Provider Business Practice Location Address Fax Number:
215-665-9242
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  SC004747-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01892600 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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