Provider Demographics
NPI:1023057015
Name:SMITH, JONATHAN G (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
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 1:109 ANDREW AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-3156
Mailing Address - Country:US
Mailing Address - Phone:508-358-3300
Mailing Address - Fax:
Practice Address - Street 1:109 ANDREW AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-3156
Practice Address - Country:US
Practice Address - Phone:508-358-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine