Provider Demographics
NPI:1750375549
Name:SMALL, JEFFREY DANIEL (MD)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DANIEL
Last Name:SMALL
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 1:4695 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-372-4419
Mailing Address - Fax:
Practice Address - Street 1:4695 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1802
Practice Address - Country:US
Practice Address - Phone:203-372-4419
Practice Address - Fax:203-372-4919
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030495208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001304956Medicaid
CT001304956Medicaid
CT340000274Medicare ID - Type Unspecified