Provider Demographics
NPI:1548594542
Name:SMITH, DONALD RAY JR (PA)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RAY
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 CUMBERLAND TRL
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75181-2164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2533 CUMBERLAND TRL
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75181-2164
Practice Address - Country:US
Practice Address - Phone:850-393-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332886363A00000X
FLPA9105176363A00000X
TXPA08849363A00000X
IDPA-2644363A00000X
WI4212-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001640200Medicaid
FLCR580ZOtherMEDICARE
TX382340YKP5Medicare PIN
FL001640200Medicaid