Provider Demographics
NPI:1811919285
Name:SMITH, MARK DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
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 1:7100 OAKMONT BLVD. STE 108
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132
Mailing Address - Country:US
Mailing Address - Phone:817-370-2657
Mailing Address - Fax:817-370-2186
Practice Address - Street 1:7100 OAKMONT BLVD. STE 108
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132
Practice Address - Country:US
Practice Address - Phone:817-370-2657
Practice Address - Fax:817-370-2186
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5975207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0986929-02Medicaid
TX00H23SMedicare ID - Type UnspecifiedMEDICARE
TXE61721Medicare UPIN
TX0986929-02Medicaid
00H235Medicare PIN