Healthcare Provider Details

I. General information

NPI: 1407992381
Provider Name (Legal Business Name): KENNETH R SMITH D. O. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 N 43RD AVE SUITE 1
GLENDALE AZ
85301-5488
US

IV. Provider business mailing address

6040 N 43RD AVE SUITE 1
GLENDALE AZ
85301-5488
US

V. Phone/Fax

Practice location:
  • Phone: 623-931-2221
  • Fax:
Mailing address:
  • Phone: 623-931-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number1718
License Number StateAZ

VIII. Authorized Official

Name: KENNETH R SMITH
Title or Position: PRESIDENT
Credential: D.O.
Phone: 623-931-2221