Provider Demographics
NPI:1871533752
Name:SMITH, GREGORY HEATH (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:HEATH
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7304
Mailing Address - Country:US
Mailing Address - Phone:817-250-4280
Mailing Address - Fax:
Practice Address - Street 1:800 5TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7304
Practice Address - Country:US
Practice Address - Phone:817-250-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3905207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130841309Medicaid
TX130841307Medicaid
TXD97903Medicare UPIN
TXTXB165910Medicare PIN
TXTXB165884Medicare PIN
TX8826J4Medicare ID - Type Unspecified
TX130841307Medicaid