Provider Demographics
NPI:1669887899
Name:SMITH, ELLYN ALLYSE (MD)
Entity type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:ALLYSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:185 ROSEBERRY ST
Mailing Address - Street 2:FARLEY BLDG 2ND FLOOR
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1690
Mailing Address - Country:US
Mailing Address - Phone:908-847-2621
Mailing Address - Fax:908-847-3045
Practice Address - Street 1:333 CITY BLVD W STE 1600
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-5903
Practice Address - Country:US
Practice Address - Phone:714-456-8598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT206685208600000X
CAA160672208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery