Provider Demographics
NPI:1578608865
Name:SMITH, GERALD WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 STOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1638
Mailing Address - Country:US
Mailing Address - Phone:318-251-2331
Mailing Address - Fax:
Practice Address - Street 1:104 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5953
Practice Address - Country:US
Practice Address - Phone:318-255-2463
Practice Address - Fax:318-255-2463
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA336111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAT5574Medicare UPIN
LA59318Medicare ID - Type Unspecified