Provider Demographics
NPI:1386600427
Name:SMITH, DONALD (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-1620
Mailing Address - Country:US
Mailing Address - Phone:662-447-3882
Mailing Address - Fax:662-447-2265
Practice Address - Street 1:119 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1620
Practice Address - Country:US
Practice Address - Phone:662-447-3882
Practice Address - Fax:662-447-2265
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013366Medicaid
MS00013366Medicaid
MSB31192Medicare UPIN