Provider Demographics
NPI:1861456584
Name:SMITH, JUDSON P III (MD PA)
Entity Type:Individual
Prefix:
First Name:JUDSON
Middle Name:P
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-338-4081
Mailing Address - Fax:817-870-1612
Practice Address - Street 1:417 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-338-4081
Practice Address - Fax:817-870-1612
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9667207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1215156120OtherBLUE CROSS BLUE SHIELD
TX1493934-01Medicaid
TX0004246771OtherAETNA
TX180000666OtherRAILROAD MEDICARE
TXC21998Medicare UPIN
TX1493934-01Medicaid