Healthcare Provider Details

I. General information

NPI: 1891508628
Provider Name (Legal Business Name): MARY KATHERINE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 OLD STERLINGTON RD APT 141
MONROE LA
71203-2611
US

IV. Provider business mailing address

3111 OLD STERLINGTON RD APT 141
MONROE LA
71203-2611
US

V. Phone/Fax

Practice location:
  • Phone: 318-334-0858
  • Fax:
Mailing address:
  • Phone: 318-334-0858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number344075
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: