Provider Demographics
NPI:1417443672
Name:SMITH, CHELSEA COLVIN
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:COLVIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 VIKING DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2165
Mailing Address - Country:US
Mailing Address - Phone:318-747-8100
Mailing Address - Fax:
Practice Address - Street 1:2539 VIKING DR STE 101
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2165
Practice Address - Country:US
Practice Address - Phone:318-747-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP.10117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine