1417996448 NPI number — DR. JERRY ALTON SMITH M.D.

Table of content: DR. JERRY ALTON SMITH M.D. (NPI 1417996448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417996448 NPI number — DR. JERRY ALTON SMITH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JERRY
Provider Middle Name:
ALTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
JERRY
Provider Other Middle Name:
ALTON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417996448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2034
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71273-2034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-513-1950
Provider Business Mailing Address Fax Number:
318-513-1952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 S VIENNA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-5830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-513-1950
Provider Business Practice Location Address Fax Number:
318-513-1952
Provider Enumeration Date:
06/05/2006

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: 207Q00000X , with the licence number:  018988 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1691542 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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