Provider Demographics
NPI:1962504357
Name:SMITH, JEFFREY RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
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 1:14 WEST GORE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:321-843-5001
Mailing Address - Fax:321-843-5085
Practice Address - Street 1:14 WEST GORE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:321-843-5001
Practice Address - Fax:321-843-5085
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072971208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256468800Medicaid
FL46648OtherBLUE CROSS BLUE SHIELD
FL46648ZMedicare ID - Type Unspecified
FL46648XMedicare PIN
H08210Medicare UPIN
FL46648YMedicare PIN