Provider Demographics
NPI:1053410183
Name:SMALL, JENNIFER REBECCA (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:REBECCA
Last Name:SMALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 SARANAC AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1185
Mailing Address - Country:US
Mailing Address - Phone:518-523-1530
Mailing Address - Fax:518-531-6831
Practice Address - Street 1:2237 SARANAC AVE
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1185
Practice Address - Country:US
Practice Address - Phone:518-523-1530
Practice Address - Fax:518-531-6831
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006871152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU63811Medicare UPIN
IA0813Medicare ID - Type Unspecified