Provider Demographics
NPI:1669458162
Name:SMITH, BRIAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22510
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2510
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-255-5631
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-2200
Practice Address - Fax:901-255-5631
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079800207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079800Medicaid
249170Medicare ID - Type Unspecified