Basic Information
| Provider Information | |||||||||
| NPI: | 1194742791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8179200068 | ||||||||
| Practice Location | |||||||||
| Address1: | 923 PENNSYLVANIA AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179200484 | ||||||||
| FaxNumber: | 8179200068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 01/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | L1204 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | P00413563 | 01 | RAILROAD MEDICARE | OTHER | 176348402 | 01 | TX | MEDICAID CSHCN | OTHER | 176348401 | 05 | TX | MEDICAID |