Provider Demographics
NPI:1043248818
Name:SMITH, JACK DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:DALE
Other - Last Name:SMITH
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 COTTONWOOD ST
Practice Address - Street 2:SUITE 302
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5131
Practice Address - Country:US
Practice Address - Phone:530-666-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37180208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G371800OtherBLUE SHIELD
CA00G371800Medicaid
CAP00745248OtherMEDICARE RAILROAD CARRIER
CA00G371802Medicare PIN
CAP00745248OtherMEDICARE RAILROAD CARRIER
CA00G371800Medicare ID - Type Unspecified