Healthcare Provider Details

I. General information

NPI: 1356310650
Provider Name (Legal Business Name): KENNETH B SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 HOUMA BLVD FL 3
METAIRIE LA
70006-2970
US

IV. Provider business mailing address

4200 HOUMA BLVD FL 3
METAIRIE LA
70006-2970
US

V. Phone/Fax

Practice location:
  • Phone: 504-503-5205
  • Fax: 504-503-6019
Mailing address:
  • Phone: 504-503-5205
  • Fax: 504-503-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number12364
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberMD.012364
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: