Provider Demographics
NPI:1124253521
Name:SMALLWOOD, JEREMY K (RPA/RA, RT(R)(VI))
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:K
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:RPA/RA, RT(R)(VI)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4361
Mailing Address - Country:US
Mailing Address - Phone:228-818-1117
Mailing Address - Fax:228-818-6090
Practice Address - Street 1:3109 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4361
Practice Address - Country:US
Practice Address - Phone:228-818-1117
Practice Address - Fax:228-818-6090
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS243U00000X, 2471V0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology