Provider Demographics
NPI:1790309565
Name:SMITH, JASON C (IDC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BARRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:MAPLE HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28454-8659
Mailing Address - Country:US
Mailing Address - Phone:205-908-2066
Mailing Address - Fax:
Practice Address - Street 1:113 BARRINGTON CT
Practice Address - Street 2:
Practice Address - City:MAPLE HILL
Practice Address - State:NC
Practice Address - Zip Code:28454-8659
Practice Address - Country:US
Practice Address - Phone:205-908-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1290344375OtherUNITED STATES NAVY