Provider Demographics
NPI:1083025134
Name:SMITHSON, CLINTON CHARLES III (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:CHARLES
Last Name:SMITHSON
Suffix:III
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-606-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10050385207P00000X
TXQ5722207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-044OtherTRICARE
TX75-1976930-005OtherTRICARE
TX525037YS6POtherMEDICARE
TX75-0818167-048OtherTRICARE
TX75-0818167-051OtherTRICARE
TXBP10050385OtherPHYSICIAN IN TRAINING PERMIT NUMBER
TXP01855291OtherMCRR
TX362583206Medicaid
TX525037YS6VOtherMEDICARE
TXP01855287OtherMEDICARE RAIL ROAD
TX362583207Medicaid
TX75-0818167-015OtherTRICARE