Healthcare Provider Details

I. General information

NPI: 1831137041
Provider Name (Legal Business Name): CHARLES D SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE J 401
LEXINGTON KY
40536-0284
US

IV. Provider business mailing address

740 S LIMESTONE J 401
LEXINGTON KY
40536-0284
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5661
  • Fax:
Mailing address:
  • Phone: 859-323-5661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25444
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number25444
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25444
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: