Provider Demographics
NPI:1063415446
Name:SMITH, MARK B (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3078
Mailing Address - Country:US
Mailing Address - Phone:512-708-1234
Mailing Address - Fax:512-708-4567
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78723-3078
Practice Address - Country:US
Practice Address - Phone:512-708-1234
Practice Address - Fax:512-708-4567
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH1021208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112887801Medicaid
TX139781201Medicaid
TX139781201Medicaid
TX112887801Medicaid
E94579Medicare UPIN