MEDICARE: MR. JESSE E SMITH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	L1204	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00413563	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1194742791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE E SMITH MD

Provider Business Mailing Address
First Line	:	923 PENNSYLVANIA AVE
Second Line	:	STE 100
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2254
Country	:	US
Telephone Number	:	817-806-4245
Fax Number	:	817-720-0094

Provider Business Practice Location Address
First Line	:	923 PENNSYLVANIA AVE
Second Line	:	STE 100
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2254
Country	:	US
Telephone Number	:	817-806-4245
Fax Number	:	817-720-0094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/12/2025

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Directions to “ MR. JESSE E SMITH MD” Practice Location

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