Provider Demographics
NPI:1821027335
Name:SMITH, JASON V (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:V
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 7237
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7237
Mailing Address - Country:US
Mailing Address - Phone:228-863-6617
Mailing Address - Fax:228-863-1747
Practice Address - Street 1:3017 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-1833
Practice Address - Country:US
Practice Address - Phone:228-863-6617
Practice Address - Fax:228-863-1747
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07932207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS040000120Medicare ID - Type UnspecifiedMEDICARE
MSD00654Medicare UPIN