=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497209548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY SMITH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2016
-----------------------------------------------------
Last Update Date | 10/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10301 GATEWAY BLVD W
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-373-3449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10201 GATEWAY BLVD W STE 130
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79925-7647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-594-1000
-----------------------------------------------------
Fax | 915-594-1007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | TRN25581
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2016022430
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | T7743
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------