Provider Demographics
NPI:1639324171
Name:SMITH, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-2026
Mailing Address - Country:US
Mailing Address - Phone:806-722-0076
Mailing Address - Fax:806-791-4937
Practice Address - Street 1:3518 26TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2026
Practice Address - Country:US
Practice Address - Phone:806-722-0076
Practice Address - Fax:806-791-4937
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TX0A0109Medicare PIN