Provider Demographics
NPI:1558451773
Name:SMITH, THERESA T (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:T
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 MCCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9686
Mailing Address - Country:US
Mailing Address - Phone:731-661-0696
Mailing Address - Fax:
Practice Address - Street 1:587 MCCLELLAN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-9686
Practice Address - Country:US
Practice Address - Phone:731-661-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000022199208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3067011Medicaid
TNF26972Medicare UPIN