Provider Demographics
NPI:1659460590
Name:SMITH, JERRY M JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:M
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10213 TRUETT LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3642
Mailing Address - Country:US
Mailing Address - Phone:360-689-0241
Mailing Address - Fax:
Practice Address - Street 1:4643 DOCK RD
Practice Address - Street 2:BLDG 524
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4321
Practice Address - Country:US
Practice Address - Phone:805-982-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman