Provider Demographics
NPI:1003851429
Name:SMITH, AMITY L (MD)
Entity Type:Individual
Prefix:DR
First Name:AMITY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMITY
Other - Middle Name:S
Other - Last Name:MATTEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:601 ZENA RUCKER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-488-2837
Mailing Address - Fax:817-488-6335
Practice Address - Street 1:601 ZENA RUCKER RD STE 105
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6387
Practice Address - Country:US
Practice Address - Phone:817-488-2837
Practice Address - Fax:817-488-6335
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G1709Medicare ID - Type Unspecified