Provider Demographics
NPI:1760402713
Name:SMITH, JARVIS WILTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JARVIS
Middle Name:WILTON
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:PO BOX 1717
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-1717
Mailing Address - Country:US
Mailing Address - Phone:336-538-1234
Mailing Address - Fax:336-538-2390
Practice Address - Street 1:1234 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1234
Practice Address - Fax:336-538-2390
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29174208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911807Medicaid
NC203461Medicare ID - Type Unspecified
NC8911807Medicaid