Provider Demographics
NPI:1023075983
Name:SMITH, JAMES LACEY (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LACEY
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 1:1207 MARINA COVE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2285
Mailing Address - Country:US
Mailing Address - Phone:901-412-1881
Mailing Address - Fax:
Practice Address - Street 1:1207 MARINA COVE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:901-412-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19469207RG0100X
GA075543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3064885Medicaid
TN3064885Medicaid
TN3064885Medicaid