Provider Demographics
NPI:1336463264
Name:JEREMY SMITH MD PA
Entity Type:Organization
Organization Name:JEREMY SMITH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-645-6008
Mailing Address - Street 1:1320 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4269
Mailing Address - Country:US
Mailing Address - Phone:936-559-9225
Mailing Address - Fax:936-559-7911
Practice Address - Street 1:1320 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4269
Practice Address - Country:US
Practice Address - Phone:936-559-9225
Practice Address - Fax:936-559-7911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI26437Medicare UPIN