Provider Demographics
NPI:1154624195
Name:J SCOTT SMITH MD PA
Entity type:Organization
Organization Name:J SCOTT SMITH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-598-8120
Mailing Address - Street 1:1321 WATER'S EDGE DR. 1010-4
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048
Mailing Address - Country:US
Mailing Address - Phone:817-598-8120
Mailing Address - Fax:682-936-4323
Practice Address - Street 1:1321 WATER'S EDGE DR. 1010-4
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048
Practice Address - Country:US
Practice Address - Phone:817-598-8120
Practice Address - Fax:682-936-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8AN010OtherBLUE CROSS BLUE SHIELD
8AN010OtherBLUE CROSS BLUE SHIELD