Provider Demographics
NPI:1003989708
Name:SMITH, JERRY RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:RANDOLPH
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 1:3015 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1961
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:502-772-4785
Practice Address - Street 1:3015 WILSON AVE
Practice Address - Street 2:PARK DUVALLE CNC
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211
Practice Address - Country:US
Practice Address - Phone:502-774-4401
Practice Address - Fax:502-772-4783
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64181092Medicaid
0746102Medicare ID - Type Unspecified
KY64181092Medicaid