Provider Demographics
NPI:1821041245
Name:SMOLIN, MATTHEW RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:SMOLIN
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 1:301 JUNCTION HWY STE 220
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4203
Mailing Address - Country:US
Mailing Address - Phone:830-896-3730
Mailing Address - Fax:830-792-4402
Practice Address - Street 1:1 MERCADO ST STE 130
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-247-1120
Practice Address - Fax:970-247-1120
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9691207RC0000X, 207RI0011X
CODR.0027306207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01632354OtherRR MEDICARE
CO54830052Medicaid
CO54830052Medicaid
CO473819YQNHMedicare PIN
CO473815YUH0Medicare PIN
TNF82329Medicare UPIN
AR165499001Medicaid
TN3084309Medicaid
103I421310Medicare PIN
TN8200OtherTLC PROVIDER NUMBER
TN4480407OtherAETNA PROVIDER NUMBER
TN4277746OtherBCBS TN
TN3084308Medicare ID - Type UnspecifiedMEDICARE
MS00088237Medicaid