Provider Demographics
NPI:1063402295
Name:SMITH, STEPHEN REILLY (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:REILLY
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 1:7200 N MOPAC EXPY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3069
Mailing Address - Country:US
Mailing Address - Phone:512-241-1806
Mailing Address - Fax:512-623-7892
Practice Address - Street 1:7200 N MOPAC EXPY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3069
Practice Address - Country:US
Practice Address - Phone:512-241-1806
Practice Address - Fax:512-623-7892
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4952207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66385865Medicaid
P01010506OtherRR MEDICARE
TX184558802Medicaid
TX184558802Medicaid
NM66385865Medicaid
P00353271Medicare PIN