Provider Demographics
NPI:1851574032
Name:TYLER OFFICE OF PEDIATRICS P A
Entity Type:Organization
Organization Name:TYLER OFFICE OF PEDIATRICS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-3220
Mailing Address - Street 1:PO BOX 131866
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-1866
Mailing Address - Country:US
Mailing Address - Phone:903-595-3220
Mailing Address - Fax:903-595-3887
Practice Address - Street 1:4801 TROUP HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2356
Practice Address - Country:US
Practice Address - Phone:903-595-3220
Practice Address - Fax:903-595-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118586004Medicaid
TX043902803Medicaid