Basic Information
| Provider Information | |||||||||
| NPI: | 1912903741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 3240 IRVIN COBB DR | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420030337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704439474 | ||||||||
| FaxNumber: | 2704439477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36603 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64035058 | 05 | KY | MEDICAID |