Healthcare Provider Details

I. General information

NPI: 1710140314
Provider Name (Legal Business Name): JASON ANTHONY SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEDICAL CENTER PKWY
MAUMEE OH
43537-1921
US

IV. Provider business mailing address

2200 JEFFERSON AVE 5TH FL
TOLEDO OH
43604-7101
US

V. Phone/Fax

Practice location:
  • Phone: 419-794-2593
  • Fax: 419-517-8188
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101022929
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0102203247
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number34009703
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: