Provider Demographics
NPI:1528478203
Name:SMITH, JORDAN K (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:K
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:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-606-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10050384207P00000X
TXQ6470207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3555558312Medicaid
TX355558313Medicaid
TX75-0818167-051OtherTRICARE
TX75-0818167-048OtherTRICARE
TX75-1976930-005OtherTRICARE
TX75-0818167-044OtherTRICARE
TXP01878587OtherMEDICARE RAIL ROAD
TXP01878809OtherMEDICARE RAIL ROAD
TX8GY137OtherBCBS
TX75-0818167-015OtherTRICARE
TX481599YSVOtherMEDICARE
TX481599YSPOtherMEDICARE