Basic Information
Provider Information | |||||||||
NPI: | 1750309506 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 695 US HIGHWAY 46 | ||||||||
Address2: | SUITE 400A | ||||||||
City: | FAIRFIELD | ||||||||
State: | NJ | ||||||||
PostalCode: | 070041592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738268080 | ||||||||
FaxNumber: | 8663093354 | ||||||||
Practice Location | |||||||||
Address1: | 1400 CREEK WAY DR | ||||||||
Address2: | SUITE 201A | ||||||||
City: | SUGAR LAND | ||||||||
State: | TX | ||||||||
PostalCode: | 774784072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8327703180 | ||||||||
FaxNumber: | 8882485252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 04/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA02366 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 181633201 | 05 | TX |   | MEDICAID | 8N3694 | 01 | TX | BCBS | OTHER |