Healthcare Provider Details

I. General information

NPI: 1336283803
Provider Name (Legal Business Name): KEVIN WILLIAM SMALLWOOD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN-STANTON DR SUITE 1E50
NEWARK DE
19718
US

IV. Provider business mailing address

4755 OGLETOWN-STANTON RD, SUITE 1E50
NEWARK DE
19718
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1980
  • Fax: 302-733-1986
Mailing address:
  • Phone: 302-733-1980
  • Fax: 302-733-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0001161
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberCS-0000589
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0001161
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: