Basic Information
| Provider Information | |||||||||
| NPI: | 1043494800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CLARK | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 FORT WASHINGTON AVE | ||||||||
| Address2: | SUITE 199 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123053535 | ||||||||
| FaxNumber: | 2123421470 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 FORT WASHINGTON AVE | ||||||||
| Address2: | SUITE 199 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123053535 | ||||||||
| FaxNumber: | 2123421470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2007 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 260227 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 260227 | NY | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.