1174529887 NPI number — MARK ALAN SMITH MD

Table of content: MARK ALAN SMITH MD (NPI 1174529887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174529887 NPI number — MARK ALAN SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MARK
Provider Middle Name:
ALAN
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1174529887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5308 RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72076-8907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-681-6181
Provider Business Mailing Address Fax Number:
501-983-4376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SHADOW OAKS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERWOOD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72120-6046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-681-6181
Provider Business Practice Location Address Fax Number:
501-983-4376
Provider Enumeration Date:
06/27/2005

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: 207R00000X , with the licence number:  E4293 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 155886001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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