Basic Information
| Provider Information | |||||||||
| NPI: | 1114137064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | LANDON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1308 WONDER WORLD DR | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786667532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123965199 | ||||||||
| FaxNumber: | 5124544575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | M6888 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 281056602 | 05 | TX | MEDICAID | BP1-0017729 | 01 | INSTITUTIONAL PERMIT | OTHER | 281056601 | 05 | TX | MEDICAID | P00998373 | 01 | TX | RAILROAD MEDICARE | OTHER |