Provider Demographics
NPI:1326111790
Name:SMITH, MARK WINSTON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WINSTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-7693
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:2602 SAINT MICHAEL DR STE 400
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-614-5670
Practice Address - Fax:903-614-5674
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96979207R00000X
TXR3217207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX391703101Medicaid