Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 10838 | MS |
Y | 207Q00000X | Family Doctor | 10838 | MS |
NPI | 1003981879 |
---|---|
Provider Name | Robert Smith |
First Address | West Point, MS 39773-9317 |
Second Address | West Point, MS 39773-9317 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 18/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00019424 | (05) | MS |
02530579 | (05) | MS |
113650710 | BCBS (01) | MS |
D80535 | (02) | MS |