Provider Demographics
NPI:1497839070
Name:SMITH, BERT JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:JACKSON
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 1:2717 EAST OAKLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1843
Mailing Address - Country:US
Mailing Address - Phone:423-926-2358
Mailing Address - Fax:423-926-2680
Practice Address - Street 1:2717 E. OAKLAND AVENUE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-926-2358
Practice Address - Fax:276-258-4056
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43425207R00000X, 208000000X
VA0101256885207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506626Medicaid
KY7100075230Medicaid
TN1506627Medicaid
VA1497839070Medicaid
TNQ002701Medicaid
NC1497839070Medicaid
TNP00844330OtherRR MEDICARE
NC5913158Medicaid
TN1506626Medicaid
VAVVJ282AMedicare PIN