Provider Demographics
NPI:1396709689
Name:SMITH, JACQUELINE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:ELIZABETH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4101 NW 4TH ST
Mailing Address - Street 2:# 409
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2836
Mailing Address - Country:US
Mailing Address - Phone:954-321-9555
Mailing Address - Fax:954-321-9557
Practice Address - Street 1:4101 NW 4TH ST
Practice Address - Street 2:# 409
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2850
Practice Address - Country:US
Practice Address - Phone:954-321-9555
Practice Address - Fax:954-321-9557
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL71500207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251684500Medicaid
FLG35291Medicare UPIN
FL32364AMedicare ID - Type Unspecified