Healthcare Provider Details

I. General information

NPI: 1205081320
Provider Name (Legal Business Name): JOHN WESLEY SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SERIO BLVD
FERRIDAY LA
71334
US

IV. Provider business mailing address

204 SERIO BLVD.
FERRIDAY LA
71334
US

V. Phone/Fax

Practice location:
  • Phone: 318-757-8010
  • Fax: 318-757-9501
Mailing address:
  • Phone: 318-757-8010
  • Fax: 318-757-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.205642
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: