Healthcare Provider Details

I. General information

NPI: 1174707368
Provider Name (Legal Business Name): STEPHEN KEITH SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3100
  • Fax: 601-200-3109
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21788
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: