MEDICARE: DR. JERRY ALTON SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	018988	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417996448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY ALTON SMITH M.D.

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

Provider Business Practice Location Address
First Line	:	902 S VIENNA ST
Second Line	:
City	:	RUSTON
State	:	LA
Zip	:	71270-5830
Country	:	US
Telephone Number	:	318-513-1950
Fax Number	:	318-513-1952

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/31/2011

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