Provider Demographics
NPI:1184685158
Name:SMITH, RUSSEL N III (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:N
Last Name:SMITH
Suffix:III
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 1:201 SUNRISE RD
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71343-5308
Mailing Address - Country:US
Mailing Address - Phone:318-758-1469
Mailing Address - Fax:
Practice Address - Street 1:5900 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3714
Practice Address - Country:US
Practice Address - Phone:318-386-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59098491205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6204Medicaid
UTD6204Medicaid
UT006486039Medicare ID - Type Unspecified