Healthcare Provider Details

I. General information

NPI: 1184656068
Provider Name (Legal Business Name): ROBERT ALLEN SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 N. STATE ST. STE. 504
JACKSON MS
39202-1658
US

IV. Provider business mailing address

1424 NORTH STATE ST. SUITE 504
JACKSON MS
39202-1658
US

V. Phone/Fax

Practice location:
  • Phone: 601-969-9050
  • Fax: 601-954-2443
Mailing address:
  • Phone: 601-969-9050
  • Fax: 601-954-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number5848
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: