Provider Demographics
NPI:1740224567
Name:SMITH, GRAYSON (MD)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
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 1:1305 WONDER WORLD DR
Mailing Address - Street 2:STE 206
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7546
Mailing Address - Country:US
Mailing Address - Phone:512-396-1525
Mailing Address - Fax:512-353-2530
Practice Address - Street 1:1305 WONDER WORLD DR
Practice Address - Street 2:STE 206
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7546
Practice Address - Country:US
Practice Address - Phone:512-396-1525
Practice Address - Fax:512-353-2530
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX042439202Medicaid
TX8R5960OtherBCBS
TX8D1527Medicare PIN
TX042439202Medicaid