Basic Information
| Provider Information | |||||||||
| NPI: | 1710140314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE | ||||||||
| Address2: | 5TH FL | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7640 SYLVANIA AVE | ||||||||
| Address2: | SUITE A-1 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435609729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195178178 | ||||||||
| FaxNumber: | 4195178188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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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 | 207XX0005X | 0102203247 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207QS0010X | 34009703 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 5101022929 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1710140314 | 05 | VA | MEDICAID |