Provider Demographics
NPI:1528247277
Name:E. CLYDE SMOOT, M.D.-LLC
Entity type:Organization
Organization Name:E. CLYDE SMOOT, M.D.-LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:CLYDE
Authorized Official - Last Name:SMOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-478-5577
Mailing Address - Street 1:4150 NELSON RD
Mailing Address - Street 2:BLDG A STE 2
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-478-5577
Mailing Address - Fax:337-478-5588
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BLDG A STE 2
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-478-5577
Practice Address - Fax:337-478-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD12854R2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1978671Medicaid
LAD89956Medicare UPIN
LA5BC88Medicare PIN