Provider Demographics
NPI:1922539030
Name:SMITH, TYLER GIBSON
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:GIBSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-702-1173
Mailing Address - Fax:
Practice Address - Street 1:115 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2105
Practice Address - Country:US
Practice Address - Phone:903-885-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0225207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX412047903Medicaid
TX412047904Medicaid