Provider Demographics
NPI:1265419949
Name:SMITH, PHILIP O (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:O
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 97
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:TX
Mailing Address - Zip Code:75097-0097
Mailing Address - Country:US
Mailing Address - Phone:214-405-8930
Mailing Address - Fax:
Practice Address - Street 1:8041 N MACARTHUR BLVD APT 2177
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-7663
Practice Address - Country:US
Practice Address - Phone:214-405-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7180207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089722504Medicaid
TX089722504Medicaid
TX343600Medicare PIN