Provider Demographics
NPI:1699779652
Name:SMITH, GARY L (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
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:PO BOX 60170
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0170
Mailing Address - Country:US
Mailing Address - Phone:361-882-3487
Mailing Address - Fax:361-882-3811
Practice Address - Street 1:5402 S STAPLES ST
Practice Address - Street 2:STE 205
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4670
Practice Address - Country:US
Practice Address - Phone:361-882-3487
Practice Address - Fax:361-882-3811
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDH3177207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120650004Medicaid
TX84530YOtherBCBS OF TX PROVIDER NO
TX120650004Medicaid
TX84530YOtherBCBS OF TX PROVIDER NO