Provider Demographics
NPI:1457315301
Name:SMOTHERMAN, JASON T (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:SMOTHERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4892 N STONE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5729
Mailing Address - Country:US
Mailing Address - Phone:520-833-5200
Mailing Address - Fax:520-318-7101
Practice Address - Street 1:6565 E CARONDELET DR STE 155
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3587
Practice Address - Country:US
Practice Address - Phone:520-849-8900
Practice Address - Fax:520-849-7137
Is Sole Proprietor?:No
Enumeration Date:2006-04-15
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK18095208800000X
HI16183208800000X
AZ60976208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100114060AMedicaid
OK731521343OtherFEDERAL TAX NUMBER
OK731331909Medicare PIN
OK100114060AMedicaid