MEDICARE: DONALD RAY SMITH JR. PA

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	363A00000X	Physician Assistant	332886	LA
2	363A00000X	Physician Assistant	PA9105176	FL
3	363A00000X	Physician Assistant	PA08849	TX
4	363A00000X	Physician Assistant	PA-2644	ID
5	363A00000X	Physician Assistant	4212-23	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CR580Z	OTHER	FL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548594542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD RAY SMITH JR. PA

Provider Business Mailing Address
First Line	:	2533 CUMBERLAND TRL
Second Line	:
City	:	BALCH SPRINGS
State	:	TX
Zip	:	75181-2164
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2533 CUMBERLAND TRL
Second Line	:
City	:	BALCH SPRINGS
State	:	TX
Zip	:	75181-2164
Country	:	US
Telephone Number	:	850-393-1181
Fax Number	:

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

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	11/22/2023

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