Provider Demographics
NPI:1902882657
Name:SMAHA, JERRY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JOSEPH
Last Name:SMAHA
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 1:4501 RUSSELL PKWY
Mailing Address - Street 2:STE 11
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-953-0024
Mailing Address - Fax:478-953-0675
Practice Address - Street 1:2140 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-953-0024
Practice Address - Fax:478-953-0675
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0170872085R0202X
GA170872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000093728ZMedicaid
GA000093728KMedicaid
GAP00144376OtherRAILROAD MEDICARE
GAP00144376OtherRAILROAD MEDICARE
GAD41114Medicare UPIN