Provider Demographics
NPI:1649581059
Name:SMITH, JERRY MARK JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MARK
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:MARK
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:820 SPRINGER DR
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6413
Mailing Address - Country:US
Mailing Address - Phone:815-744-8554
Mailing Address - Fax:
Practice Address - Street 1:24 WHITE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-1411
Practice Address - Country:US
Practice Address - Phone:615-352-0011
Practice Address - Fax:615-352-0085
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN50688207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology