Provider Demographics
NPI:1154328433
Name:SMITH, MARK KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KEITH
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9969 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4106
Mailing Address - Country:US
Mailing Address - Phone:210-690-2273
Mailing Address - Fax:210-581-8209
Practice Address - Street 1:9969 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4106
Practice Address - Country:US
Practice Address - Phone:210-690-2273
Practice Address - Fax:210-581-8209
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
85276YOtherBCBS
2322005OtherBLUELINK
TX1255309-04Medicaid
16167-0010OtherPACIFICARE
873571OtherONE HEALTH
737803OtherHUMANA GOLD
2929822005OtherCIGNA HMO
2929872004OtherCIGNA POS
2044061OtherAETNA
2929872004OtherCIGNA POS
8965J7Medicare ID - Type Unspecified