Provider Demographics
NPI:1598797789
Name:SMITH, STEPHEN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ALAN
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 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5714
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:318-212-3965
Practice Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3965
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1360082Medicaid
LA1360082Medicaid
LA51332C731Medicare PIN
D79771Medicare UPIN