Provider Demographics
NPI:1699793992
Name:SMITH, ELMER G JR (MD)
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:G
Last Name:SMITH
Suffix:JR
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 1:817 MATISSE DR APT 312
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2377
Mailing Address - Country:US
Mailing Address - Phone:817-564-5073
Mailing Address - Fax:
Practice Address - Street 1:817 MATISSE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-564-5073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9424207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044073701Medicaid
TX044073702Medicaid
TX044073705Medicaid
TXTXB122463Medicare PIN
TX8587J9Medicare PIN
TXD88635Medicare UPIN
TX8936B9Medicare PIN