Provider Demographics
NPI:1457503807
Name:SMYRL, JEREMY A (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:SMYRL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 SOUTHBEND TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6301
Mailing Address - Country:US
Mailing Address - Phone:682-429-5113
Mailing Address - Fax:855-429-5113
Practice Address - Street 1:955 SOUTHBEND TRL
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6301
Practice Address - Country:US
Practice Address - Phone:682-429-5113
Practice Address - Fax:855-429-5113
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL2236390200000X
TXN3319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206079001Medicaid
TX206079002Medicaid
TX206079003Medicaid
TX206079006Medicaid
TX8L16927Medicare PIN
TX8L17057Medicare PIN
TX206079001Medicaid
TX206079006Medicaid