MEDICARE: DR. JACK W. SMITH M.D.

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	207Q00000X	Family Medicine Physician	0101033705	VA
2	207Q00000X	Family Medicine Physician	ME 51346	FL

General Provider Information

NPI Number	:	1952593691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK W. SMITH M.D.

Provider Business Mailing Address
First Line	:	3556 EARLY WOODLAND PL
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-4732
Country	:	US
Telephone Number	:	703-425-7764
Fax Number	:

Provider Business Practice Location Address
First Line	:	5111 LEESBURG PIKE
Second Line	:	SKYLINE 5, SUITE 601
City	:	FALLS CHURCH
State	:	VA
Zip	:	22041-3251
Country	:	US
Telephone Number	:	703-681-1708
Fax Number	:

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

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	08/16/2007

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