Provider Demographics
NPI:1912298498
Name:SMITH, LISA MABRY (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MABRY
Last Name:SMITH
Suffix:
Gender:F
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 10370
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-0370
Mailing Address - Country:US
Mailing Address - Phone:228-314-7226
Mailing Address - Fax:228-314-7227
Practice Address - Street 1:14257 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3369
Practice Address - Country:US
Practice Address - Phone:228-314-7226
Practice Address - Fax:228-314-7227
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL321252085R0202X
390200000X
MS248622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00536826Medicaid
MS568617YSJ9OtherMEDICARE
MS598607OtherBCBS MS
MSP01842090OtherRAILROAD MEDICARE