Healthcare Provider Details

I. General information

NPI: 1285725937
Provider Name (Legal Business Name): KENNETH PAUL SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5189 HOSPITAL RD
MARIPOSA CA
95338-9524
US

IV. Provider business mailing address

PO BOX 951
LOS BANOS CA
93635-0951
US

V. Phone/Fax

Practice location:
  • Phone: 209-966-3631
  • Fax: 209-966-8438
Mailing address:
  • Phone: 209-617-3721
  • Fax: 209-966-8438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberG68554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: