Provider Demographics
NPI:1437130135
Name:SMITH, JERALYN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JERALYN
Middle Name:S
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:706-788-2936
Practice Address - Street 1:133 W ATHENS ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-1786
Practice Address - Country:US
Practice Address - Phone:770-867-6633
Practice Address - Fax:770-867-6703
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032054208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000726327FMedicaid