Healthcare Provider Details

I. General information

NPI: 1922012509
Provider Name (Legal Business Name): MIKEL DWAINE SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GILL HEART INSTITUTE 800 ROSE ST G100
LEXINGTON KY
40536-0093
US

IV. Provider business mailing address

GILL HEART INSTITUTE 900 SOUTH LIMESTONE ST SUITE 320
LEXINGTON KY
40536-0200
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-0295
  • Fax: 859-257-8699
Mailing address:
  • Phone: 859-323-3976
  • Fax: 859-257-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22018
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number22018
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number22018
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number22018
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: