Provider Demographics
NPI:1588681167
Name:SMITH, JERRY RAND (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:RAND
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:PO BOX 6549
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70174
Mailing Address - Country:US
Mailing Address - Phone:504-433-9720
Mailing Address - Fax:504-433-9721
Practice Address - Street 1:3439 KABEL DRIVE
Practice Address - Street 2:STE 8
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131
Practice Address - Country:US
Practice Address - Phone:504-433-9720
Practice Address - Fax:504-433-9721
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1111244Medicaid
5K513Medicare ID - Type Unspecified
LA1111244Medicaid
5C805Medicare ID - Type Unspecified