Provider Demographics
NPI:1194742791
Name:SMITH, JESSE E (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-920-0068
Practice Address - Street 1:923 PENNSYLVANIA AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2254
Practice Address - Country:US
Practice Address - Phone:817-920-0484
Practice Address - Fax:817-920-0068
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL1204207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00413563OtherRAILROAD MEDICARE
TX176348402OtherMEDICAID CSHCN
TX176348401Medicaid
TX176348401Medicaid