Provider Demographics
NPI:1255913307
Name:SMITH, JONATHAN TYLER (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:TYLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 PASTURE RD BLDG 299
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89496-5000
Mailing Address - Country:US
Mailing Address - Phone:775-426-3128
Mailing Address - Fax:
Practice Address - Street 1:4755 PASTURE RD BLDG 299
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89496-5000
Practice Address - Country:US
Practice Address - Phone:775-426-3128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101283882171000000X, 208D00000X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program