Healthcare Provider Details

I. General information

NPI: 1972592038
Provider Name (Legal Business Name): KEVIN CHARLES SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 IRELAND AVE
FORT KNOX KY
40121-5111
US

IV. Provider business mailing address

2250 LEESTOWN RD ROOM 217
LEXINGTON KY
40511
US

V. Phone/Fax

Practice location:
  • Phone: 502-624-9795
  • Fax:
Mailing address:
  • Phone: 859-233-4511
  • Fax: 859-281-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03401
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number03401
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: