Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | X007938 | NY |
NPI | 1942397245 |
---|---|
Provider Name | Dr. Gary Robert Smith JR. |
First Address | Elma, NY 14059-9494 |
Second Address | Elma, NY 14059-9494 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 01/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U56216 | (02) |