Provider Demographics
NPI:1154395697
Name:SMITH, BRIAN M (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 TRI-STATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAREPTA
Mailing Address - State:LA
Mailing Address - Zip Code:71071
Mailing Address - Country:US
Mailing Address - Phone:318-994-2266
Mailing Address - Fax:318-539-9177
Practice Address - Street 1:106 TRI-STATE DRIVE
Practice Address - Street 2:
Practice Address - City:SAREPTA
Practice Address - State:LA
Practice Address - Zip Code:71071
Practice Address - Country:US
Practice Address - Phone:318-994-2266
Practice Address - Fax:318-539-9177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA26105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1629014Medicaid
138664Medicare UPIN
4J849Medicare ID - Type Unspecified