Provider Demographics
NPI:1174543029
Name:SMITH, ROLAND THEODORE (MD)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:THEODORE
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 1:635 W 165TH ST
Mailing Address - Street 2:BOX 92
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3724
Mailing Address - Country:US
Mailing Address - Phone:212-283-5222
Mailing Address - Fax:
Practice Address - Street 1:635 W 165TH ST
Practice Address - Street 2:BOX 92
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3724
Practice Address - Country:US
Practice Address - Phone:212-283-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151173-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01113964Medicaid
NY01113964Medicaid
A64639Medicare UPIN