Provider Demographics
NPI:1831113760
Name:SMITH, MICHAEL TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
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 1:1111 NORTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3831
Mailing Address - Country:US
Mailing Address - Phone:972-966-7827
Mailing Address - Fax:972-966-7899
Practice Address - Street 1:3600 GASTON AVE STE 261
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1902
Practice Address - Country:US
Practice Address - Phone:972-966-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16878207ZP0101X
TXU0660207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG31326Medicaid
SCF11131Medicare UPIN