Provider Demographics
NPI:1760578835
Name:SMITH, JEFFREY P (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
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 1:523 S FANNIN AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8204
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:
Practice Address - Street 1:214 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8131
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0026MAOtherGROUP BC/BS
TX169940701OtherGROUP MEDICAID
TX45D1034142OtherCLIA
TXJ4527OtherMEDICAL LICENSE
TX118586004Medicaid
TX8R1210OtherBLUE CROSS BLUE SHIELD
TX00850XOtherGROUP MEDICARE
TX0026MAOtherGROUP BC/BS
TX8D0094Medicare ID - Type Unspecified