Provider Demographics
NPI:1710915822
Name:SMITH, STEPHEN HARKNESS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:HARKNESS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 EXECUTIVE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6837
Mailing Address - Country:US
Mailing Address - Phone:325-227-4697
Mailing Address - Fax:325-227-4759
Practice Address - Street 1:3180 EXECUTIVE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6837
Practice Address - Country:US
Practice Address - Phone:325-227-4697
Practice Address - Fax:325-227-4759
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U8637OtherBLUE CROSS
TX134672809Medicaid
TX8K5899Medicare PIN
TXF62549Medicare UPIN
TX8U8637OtherBLUE CROSS
TX00564RMedicare PIN