Provider Demographics
NPI:1538179452
Name:SMITH, BRIAN L (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:CONVENT STATION
Mailing Address - State:NJ
Mailing Address - Zip Code:07961-0149
Mailing Address - Country:US
Mailing Address - Phone:201-841-2041
Mailing Address - Fax:973-359-8979
Practice Address - Street 1:290 MADISON AVE
Practice Address - Street 2:2A
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-7400
Practice Address - Country:US
Practice Address - Phone:973-285-1999
Practice Address - Fax:973-359-8979
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04108000208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E94752Medicare UPIN
557358Medicare ID - Type Unspecified