1912262148 NPI number — MR. STACY DOUGLAS SMITH A.T.,C

Table of content: MR. STACY DOUGLAS SMITH A.T.,C (NPI 1912262148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912262148 NPI number — MR. STACY DOUGLAS SMITH A.T.,C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
STACY
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
A.T.,C
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:
1912262148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/10/2012
NPI Reactivation Date:
06/14/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 JOHNSON AVE
Provider Second Line Business Mailing Address:
SHABAZZ
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-744-4113
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 JOHNSON AVE
Provider Second Line Business Practice Location Address:
SHABAZZ
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-744-4113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2012

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: 2255A2300X , with the licence number:  25MT00037500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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