Healthcare Provider Details

I. General information

NPI: 1710506720
Provider Name (Legal Business Name): ZACHARY MICHAEL SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone: 270-798-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0102208410
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: