Healthcare Provider Details

I. General information

NPI: 1821013400
Provider Name (Legal Business Name): VALERIE A SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RUSSELL ST
KENNETT MO
63857-2102
US

IV. Provider business mailing address

311 MAIN ST P.O. BOX 400
NEW MADRID MO
63869-1942
US

V. Phone/Fax

Practice location:
  • Phone: 573-717-1332
  • Fax: 573-717-1335
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36405
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: