Provider Demographics
NPI:1043292691
Name:SMITH, DOUGLAS N (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:N
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:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1128
Mailing Address - Country:US
Mailing Address - Phone:573-893-7848
Mailing Address - Fax:573-893-1984
Practice Address - Street 1:3308 W EDGEWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-893-7848
Practice Address - Fax:573-893-1984
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-82207Q00000X, 207QG0300X
MOR2A78207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933720Medicaid
080162220OtherRAILROAD MEDICARE
51097631OtherBLUE CROSS OF AL
51097631OtherBLUE CROSS OF AL
A10361Medicare UPIN