Provider Demographics
NPI:1275594848
Name:SMITH, JEREMY SCOTT (MD)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
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 1:3618 N. UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-205-9922
Mailing Address - Fax:936-205-9923
Practice Address - Street 1:3614 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2539
Practice Address - Country:US
Practice Address - Phone:936-205-9922
Practice Address - Fax:936-205-9923
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0573207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1748816-06Medicaid
TXPENDINGMedicare UPIN
TX1748816-06Medicaid