Provider Demographics
NPI:1134105083
Name:SMITH, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:SMITH
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:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2213
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:505 S NOLEN DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9167
Practice Address - Country:US
Practice Address - Phone:817-424-1525
Practice Address - Fax:817-424-3491
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1464207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8004K1OtherBCBS
TXG84764Medicare UPIN
TX8004K1OtherBCBS
TX00N91FMedicare PIN
TX100015741Medicare PIN