Provider Demographics
NPI:1184945115
Name:SMITH, JODY LEEANN (MD)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:LEEANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:LEEANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10201 GATEWAY BLVD W STE 130
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7647
Mailing Address - Country:US
Mailing Address - Phone:915-594-1000
Mailing Address - Fax:915-594-1007
Practice Address - Street 1:10301 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7701
Practice Address - Country:US
Practice Address - Phone:915-594-1000
Practice Address - Fax:915-594-1007
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
TXQ8794208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty