1386644953 NPI number — MR. GREGORY J SMOLARZ SR. MD

Table of content: MR. GREGORY J SMOLARZ SR. MD (NPI 1386644953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386644953 NPI number — MR. GREGORY J SMOLARZ SR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMOLARZ
Provider First Name:
GREGORY
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386644953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 HIDDEN RIDGE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-282-2713
Provider Business Mailing Address Fax Number:
469-282-0996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2602 SAINT MICHAEL DR STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-5224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-614-5670
Provider Business Practice Location Address Fax Number:
903-614-5674
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  R3725 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: G0143 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103428001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100145390A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 122489104 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83204 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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