Healthcare Provider Details

I. General information

NPI: 1417488297
Provider Name (Legal Business Name): CALEB SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

PO BOX 392518
PITTSBURGH PA
15251-9518
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-1173
  • Fax:
Mailing address:
  • Phone: 469-420-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS0569
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: