Healthcare Provider Details

I. General information

NPI: 1902059157
Provider Name (Legal Business Name): KYLE MICHAEL SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2008
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 413021
SALT LAKE CITY UT
84141-3021
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5592
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number7154798-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: