Provider Demographics
NPI:1184656068
Name:SMITH, ROBERT ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLEN
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 1:1424 NORTH STATE ST.
Mailing Address - Street 2:SUITE 504
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-969-9050
Mailing Address - Fax:601-954-2443
Practice Address - Street 1:1424 N. STATE ST.
Practice Address - Street 2:STE. 504
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-969-9050
Practice Address - Fax:601-954-2443
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5848173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS240000014Medicare ID - Type Unspecified
MSB30907Medicare UPIN