Provider Demographics
NPI:1538134572
Name:SMITH, SHANE R (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:621 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3145
Mailing Address - Country:US
Mailing Address - Phone:870-932-6799
Mailing Address - Fax:870-932-8423
Practice Address - Street 1:621 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3145
Practice Address - Country:US
Practice Address - Phone:870-932-6799
Practice Address - Fax:870-932-8423
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3427207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146939001Medicaid
ARP00062106OtherRAILROAD MEDICARE
AR5M220OtherBCBS OF AR
AR5M2207432Medicare PIN
ARH64227Medicare UPIN