Basic Information
| Provider Information | |||||||||
| NPI: | 1528053964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LIZETTE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 BROADWAY | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123150144 | ||||||||
| FaxNumber: | 2123150196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 AMSTERDAM AVE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100251737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2129615500 | ||||||||
| FaxNumber: | 2125317640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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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 | 207RG0300X | 225548 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02577324 | 05 | NY | MEDICAID |