Provider Demographics
NPI:1912903741
Name:SMITH, DAVID EARL JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EARL
Last Name:SMITH
Suffix:JR
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:3240 IRVIN COBB DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-0337
Practice Address - Country:US
Practice Address - Phone:270-443-9474
Practice Address - Fax:270-443-9477
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64035058Medicaid
KYK026710Medicare PIN
KYH38488Medicare UPIN
KY64035058Medicaid