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General NPI Number Information
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NPI Number | 1912298498
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Entity Type | Individual
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Provider Name | LISA MABRY SMITH MD
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Gender | Female
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Dates
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Enumeration Date | 05/02/2011
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Last Update Date | 09/09/2025
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Provider Practice Location Address
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Address Line | 14257 DEDEAUX RD
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City | GULFPORT
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State | MS
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Zip | 39503-3369
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Country | US
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Telephone | 228-314-7226
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Fax | 228-314-7227
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Provider Business Mailing Address
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Address Line | PO BOX 10370
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City | GULFPORT
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State | MS
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Zip | 39505-0370
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Country | US
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Telephone | 228-314-7226
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Fax | 228-314-7227
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number | ME164947
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | ME164947
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 32125
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License Number State | AL
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Taxonomy #4
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 24862
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License Number State | MS
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