Healthcare Provider Details

I. General information

NPI: 1538134572
Provider Name (Legal Business Name): SHANE R SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 E MATTHEWS AVE
JONESBORO AR
72401-3145
US

IV. Provider business mailing address

621 E MATTHEWS AVE
JONESBORO AR
72401-3145
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-6799
  • Fax: 870-932-8423
Mailing address:
  • Phone: 870-932-6799
  • Fax: 870-932-8423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberE3427
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: