Healthcare Provider Details

I. General information

NPI: 1003907304
Provider Name (Legal Business Name): KENNETH A SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 EAST DUPONT ROAD SUITE 5
FORT WAYNE IN
46825
US

IV. Provider business mailing address

1234 EAST DUPONT ROAD SUITE 1
FORT WAYNE IN
46825
US

V. Phone/Fax

Practice location:
  • Phone: 260-489-1666
  • Fax: 260-489-3255
Mailing address:
  • Phone: 260-373-9728
  • Fax: 260-459-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01022346
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: