Provider Demographics
NPI:1174707368
Name:SMITH, STEPHEN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KEITH
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-3100
Practice Address - Fax:601-200-3109
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS217882084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09034221Medicaid
MS09034221Medicaid