Provider Demographics
NPI:1497209548
Name:SMITH, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:10201 GATEWAY BLVD W STE 130
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7647
Mailing Address - Country:US
Mailing Address - Phone:915-594-1000
Mailing Address - Fax:915-594-1007
Practice Address - Street 1:10301 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7701
Practice Address - Country:US
Practice Address - Phone:309-373-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN25581208600000X
MO2016022430208600000X
TXT7743208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016022430OtherMISSOURI BOARD OF HEALING ARTS
TXT7743OtherTEXAS MEDICAL BOARD
FLTRN25581OtherFLORIDA BOARD OF MEDICINE