Provider Demographics
NPI:1134117898
Name:SMITH, SHONDRA L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHONDRA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 NELSON ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0000
Mailing Address - Country:US
Mailing Address - Phone:337-477-0011
Mailing Address - Fax:337-477-0010
Practice Address - Street 1:3635 NELSON ROAD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-0000
Practice Address - Country:US
Practice Address - Phone:337-477-0011
Practice Address - Fax:337-477-0010
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021924207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH09008Medicare UPIN
LA5E974CM87Medicare PIN