Healthcare Provider Details

I. General information

NPI: 1265812796
Provider Name (Legal Business Name): JACOB SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W CHINDEN BLVD
MERIDIAN ID
83646-6690
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2860
  • Fax:
Mailing address:
  • Phone: 208-985-1399
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRM-1467
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-13867
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: