Healthcare Provider Details

I. General information

NPI: 1316566961
Provider Name (Legal Business Name): KEVIN A SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W MICHIGAN ST # CL642
INDIANAPOLIS IN
46202-5209
US

IV. Provider business mailing address

9055 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5841
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-2686
  • Fax:
Mailing address:
  • Phone: 763-780-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number79448
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: