Provider Demographics
NPI:1578512877
Name:SMITH, GARY MARK (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARK
Last Name:SMITH
Suffix:
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:3330 MASONIC DR
Practice Address - Street 2:CHRISTUS CABRINI GROUP PRACTICE - INTENSIVISTS
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3841
Practice Address - Country:US
Practice Address - Phone:318-448-6700
Practice Address - Fax:318-483-4066
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD06275R207RC0200X
LAMD.06275R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1338133Medicaid
AR54072Medicare PIN
LA54072CU95Medicare PIN
LA1338133Medicaid
P00349293Medicare PIN