Provider Demographics
NPI:1346200938
Name:SMITH, JEFFREY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
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 1:2350 N ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3600
Mailing Address - Country:US
Mailing Address - Phone:815-971-2200
Mailing Address - Fax:815-971-9097
Practice Address - Street 1:2350 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3600
Practice Address - Country:US
Practice Address - Phone:815-971-2200
Practice Address - Fax:815-971-9097
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078927207R00000X, 207RC0001X
IL036-078927207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078927Medicaid
WI1346200938Medicaid
IL036078927Medicaid