Provider Demographics
NPI:1144203175
Name:SMITH, JEFFREY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:D
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11149 SUMMERHILL WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9077
Mailing Address - Country:US
Mailing Address - Phone:978-505-7006
Mailing Address - Fax:
Practice Address - Street 1:4170 CEDAR BLUFF DR
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-7627
Practice Address - Country:US
Practice Address - Phone:231-487-2230
Practice Address - Fax:231-487-6172
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059444208200000X
MA204149174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1144203175Medicaid
MA3208079Medicaid
MAH22447Medicare UPIN