=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831113760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL TIMOTHY SMITH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 GASTON AVE STE 261
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75246-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-966-7830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 NORTHPOINT DR
-----------------------------------------------------
City | COPPELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75019-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-966-7827
-----------------------------------------------------
Fax | 972-966-7899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | 16878
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | U0660
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------