Provider Demographics
NPI:1902938624
Name:SMOTHERS, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:SMOTHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:239 BOWLING GREEN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-5167
Mailing Address - Country:US
Mailing Address - Phone:662-834-1321
Mailing Address - Fax:662-834-5240
Practice Address - Street 1:239 BOWLING GREEN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-5167
Practice Address - Country:US
Practice Address - Phone:662-834-1321
Practice Address - Fax:662-834-5240
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17006207P00000X
MS16296207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0122914Medicaid
MS930115308OtherRAILROAD MEDICARE PTAN
MSE66059Medicare UPIN
MS389249YWZ1Medicare PIN
MS930001704Medicare PIN