Provider Demographics
NPI:1982806923
Name:SMITH, JEFFERY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:
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 1:8219 WICKER AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-627-3315
Mailing Address - Fax:219-627-3316
Practice Address - Street 1:2307 LA PORTE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7028
Practice Address - Country:US
Practice Address - Phone:219-510-5623
Practice Address - Fax:219-286-3965
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030268A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C08441Medicare UPIN