Provider Demographics
NPI:1154364974
Name:IDEMUDIA, SMART O (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:SMART
Middle Name:O
Last Name:IDEMUDIA
Suffix:
Gender:M
Credentials:MD, PHD
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 292128
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75029-2128
Mailing Address - Country:US
Mailing Address - Phone:972-420-6777
Mailing Address - Fax:972-420-0656
Practice Address - Street 1:200 W. SOUTHWEST PKWY
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067
Practice Address - Country:US
Practice Address - Phone:972-420-6777
Practice Address - Fax:972-420-0656
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ91000207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0078DMOtherBLUE CROSS / BLUE SHIELD
TXF46614OtherCOMMERCIAL
TX00187JMedicare PIN