Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD018011E | PA |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MD018011E | PA |
NPI | 1255354999 |
---|---|
Provider Name | Robert Vincent Smith |
First Address | Philadelphia, PA 19130 |
Second Address | Philadelphia, PA 19130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 24/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0007588130002 | (05) | PA |