Provider Demographics
NPI:1417996448
Name:SMITH, JERRY ALTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:ALTON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2034
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-2034
Mailing Address - Country:US
Mailing Address - Phone:318-513-1950
Mailing Address - Fax:318-513-1952
Practice Address - Street 1:902 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5830
Practice Address - Country:US
Practice Address - Phone:318-513-1950
Practice Address - Fax:318-513-1952
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1691542Medicaid
LA4E238CN30Medicare ID - Type Unspecified
LA1691542Medicaid