Healthcare Provider Details

I. General information

NPI: 1316032931
Provider Name (Legal Business Name): KENNETH WILSON SMEAD III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SHAWS CV STE 101 JOHN J. MCGUIRK VA OUTPATIENT CLINIC
NEW LONDON CT
06320-4956
US

IV. Provider business mailing address

4 SHAWS CV STE 101 JOHN J. MCGUIRK VA OUTPATIENT CLINIC
NEW LONDON CT
06320-4956
US

V. Phone/Fax

Practice location:
  • Phone: 860-437-3611
  • Fax:
Mailing address:
  • Phone: 860-437-3611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number040856
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: