Provider Demographics
NPI:1205081320
Name:SMITH, JOHN WESLEY (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WESLEY
Last Name:SMITH
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 1:204 SERIO BLVD.
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334
Mailing Address - Country:US
Mailing Address - Phone:318-757-8010
Mailing Address - Fax:318-757-9501
Practice Address - Street 1:204 SERIO BLVD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334
Practice Address - Country:US
Practice Address - Phone:318-757-8010
Practice Address - Fax:318-757-9501
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
LAMD.205642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program