Healthcare Provider Details

I. General information

NPI: 1417910720
Provider Name (Legal Business Name): ERIC W SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 E BERT KOUNS INDUSTRIAL LOOP SUITE 100
SHREVEPORT LA
71105-5634
US

IV. Provider business mailing address

1449 E BERT KOUNS INDUSTRIAL LOOP SUITE 100
SHREVEPORT LA
71105-5634
US

V. Phone/Fax

Practice location:
  • Phone: 318-629-0220
  • Fax: 318-629-0230
Mailing address:
  • Phone: 318-629-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number021641
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: