Provider Demographics
NPI:1871578989
Name:SMITH, EVANS SWANN (MD)
Entity type:Individual
Prefix:DR
First Name:EVANS
Middle Name:SWANN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 133122
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-3122
Mailing Address - Country:US
Mailing Address - Phone:903-526-4325
Mailing Address - Fax:903-526-2871
Practice Address - Street 1:833 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1905
Practice Address - Country:US
Practice Address - Phone:903-526-4325
Practice Address - Fax:903-526-2871
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0609207P00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030687001Medicaid
TX030687001Medicaid
TX00598MMedicare PIN