Provider Demographics
NPI:1447248166
Name:SHONDRA L. SMITH, MD
Entity type:Organization
Organization Name:SHONDRA L. SMITH, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHONDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-477-0011
Mailing Address - Street 1:3635 NELSON ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0000
Mailing Address - Country:US
Mailing Address - Phone:337-477-0011
Mailing Address - Fax:337-477-0010
Practice Address - Street 1:3635 NELSON ROAD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-0000
Practice Address - Country:US
Practice Address - Phone:337-477-0011
Practice Address - Fax:337-477-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CM87Medicare ID - Type Unspecified