Provider Demographics
NPI:1528064789
Name:SMITH, LOVELL BERNARD JR (MD)
Entity type:Individual
Prefix:DR
First Name:LOVELL
Middle Name:BERNARD
Last Name:SMITH
Suffix:JR
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:PO BOX 38391
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-0391
Mailing Address - Country:US
Mailing Address - Phone:901-570-1775
Mailing Address - Fax:901-853-4530
Practice Address - Street 1:554 GREEN TREE CV
Practice Address - Street 2:STE 202
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2551
Practice Address - Country:US
Practice Address - Phone:901-570-1775
Practice Address - Fax:901-853-4530
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39730208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507654Medicaid
MS08084063Medicaid
TN4313546OtherBS TN
TN103I021824OtherMEDICARE PTAN
IN200419540AMedicaid
TN1507654Medicaid