MEDICARE: DR. JACK DALE SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	G37180	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00745248	OTHER	CA	MEDICARE RAILROAD CARRIER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G371800	OTHER	CA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043248818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK DALE SMITH M.D.

Provider Business Mailing Address
First Line	:	3400 DATA DR
Second Line	:
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-7956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1321 COTTONWOOD ST
Second Line	:	SUITE 302
City	:	WOODLAND
State	:	CA
Zip	:	95695-5131
Country	:	US
Telephone Number	:	530-666-1631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	05/24/2017

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