Basic Information
Provider Information | |||||||||
NPI: | 1760578835 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 523 S FANNIN AVE | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757028204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035359041 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 214 E HOUSTON ST | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757028131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035359041 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 10/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J4527 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 0026MA | 01 | TX | GROUP BC/BS | OTHER | 169940701 | 01 | TX | GROUP MEDICAID | OTHER | 45D1034142 | 01 | TX | CLIA | OTHER | J4527 | 01 | TX | MEDICAL LICENSE | OTHER | 118586004 | 05 | TX |   | MEDICAID | 8R1210 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 00850X | 01 | TX | GROUP MEDICARE | OTHER |