Basic Information
| Provider Information | |||||||||
| NPI: | 1982842951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 733784 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753733784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828856483 | ||||||||
| FaxNumber: | 6828853113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 BOBCAT BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | TROPHY CLUB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762625135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173478100 | ||||||||
| FaxNumber: | 8173478099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N2302 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.