Basic Information
| Provider Information | |||||||||
| NPI: | 1366493736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARTHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 279 MAIN ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125611623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452553046 | ||||||||
| FaxNumber: | 8452550236 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 FAMILY PRACTICE DR | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124016449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452299055 | ||||||||
| FaxNumber: | 8453392310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 193364 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01439885 | 05 | NY | MEDICAID |