Basic Information
| Provider Information | |||||||||
| NPI: | 1215902598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 619 S FLEISHEL AVE | ||||||||
| Address2: | STE 203 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035251400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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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 | 208600000X | K4333 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | K4333 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 165577101 | 05 | TX | MEDICAID | 123912 | 01 | TX | SUPERIOR CHIPS | OTHER | 8B4096 | 01 | TX | BCBS OF TEXAS | OTHER | 7254364 | 01 | TX | AETNA | OTHER | 752616977021 | 01 | TX | TRICARE | OTHER |