Basic Information
| Provider Information | |||||||||
| NPI: | 1538228622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ELLAWESE | ||||||||
| MiddleName: | YVONNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 WALTER REED BLVD STE 305 | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750423719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722766100 | ||||||||
| FaxNumber: | 9722761231 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 ANALOG DR | ||||||||
| Address2: | |||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750811944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722766100 | ||||||||
| FaxNumber: | 9722761231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | J1485 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8P2162 | 01 | TX | BCBS | OTHER | 0075HS | 01 | TX | BCBS | OTHER | 131205010 | 05 | TX | MEDICAID |