Provider Demographics
NPI:1417997909
Name:SMITH, JASON HENRY (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:HENRY
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 1:900 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-4255
Mailing Address - Country:US
Mailing Address - Phone:229-227-5158
Mailing Address - Fax:229-227-5187
Practice Address - Street 1:259 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1410
Practice Address - Country:US
Practice Address - Phone:229-336-1949
Practice Address - Fax:229-336-1436
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15804Medicare UPIN