Provider Demographics
NPI:1336345263
Name:SMITH, JORDAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
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 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-9345
Mailing Address - Fax:
Practice Address - Street 1:323 E RIVERSIDE DR STE 224
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6865
Practice Address - Country:US
Practice Address - Phone:208-302-6000
Practice Address - Fax:208-302-6055
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD166846207R00000X
CAA105728207R00000X
IDM-15536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine