Provider Demographics
NPI:1790756039
Name:SMOOT, ERNEST CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:CLYDE
Last Name:SMOOT
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 1:4150 NELSON RD
Mailing Address - Street 2:BLDG. A, STE. 2
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-478-5577
Mailing Address - Fax:337-478-5588
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BLDG. A, STE. 2
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-478-5577
Practice Address - Fax:337-478-5588
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12854R2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1978671Medicaid
LA1978671Medicaid
LAD89956Medicare UPIN