Provider Demographics
NPI:1710671722
Name:SMITH, TONY D
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:D
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 1:25435 NORTHPARK LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-7441
Mailing Address - Country:US
Mailing Address - Phone:216-259-2299
Mailing Address - Fax:
Practice Address - Street 1:25435 NORTHPARK LAKE DR
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-7441
Practice Address - Country:US
Practice Address - Phone:216-259-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46342585172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver