Healthcare Provider Details

I. General information

NPI: 1962067439
Provider Name (Legal Business Name): KENNETH GEORGE SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 APPLE VALLEY ROAD
HIGH ROLLS NM
88325
US

IV. Provider business mailing address

PO BOX 442
HIGH ROLLS MOUNTAIN PARK NM
88325-0442
US

V. Phone/Fax

Practice location:
  • Phone: 575-632-1134
  • Fax:
Mailing address:
  • Phone: 575-682-1134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number73-70
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: