=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417997909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON HENRY SMITH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2006
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 259 US HIGHWAY 19 N
-----------------------------------------------------
City | CAMILLA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31730-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-336-1949
-----------------------------------------------------
Fax | 229-336-1436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 CAIRO RD
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-4255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-227-5158
-----------------------------------------------------
Fax | 229-227-5187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 057188
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------