Provider Demographics
NPI:1578586400
Name:SMITH, JASON L (M D)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1419
Mailing Address - Country:US
Mailing Address - Phone:706-235-7711
Mailing Address - Fax:706-235-9944
Practice Address - Street 1:103 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:706-235-7711
Practice Address - Fax:706-235-9944
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032302207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000398384BMedicaid
GA07BDCMQMedicare PIN
GAB61951Medicare UPIN