Healthcare Provider Details

I. General information

NPI: 1184714917
Provider Name (Legal Business Name): KRISTIN N SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E MADISON ST
SOUTH BEND IN
46617-2322
US

IV. Provider business mailing address

PO BOX 809
GOSHEN IN
46527-0809
US

V. Phone/Fax

Practice location:
  • Phone: 574-283-1234
  • Fax:
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberK4332
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: