Provider Demographics
NPI:1003907304
Name:SMITH, KENNETH A (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 EAST DUPONT ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-373-9728
Mailing Address - Fax:260-459-5664
Practice Address - Street 1:1234 EAST DUPONT ROAD
Practice Address - Street 2:SUITE 5
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-489-1666
Practice Address - Fax:260-489-3255
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022346207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100108770AMedicaid
IN000000637485OtherANTHEM
1866OtherPHP
000000206530OtherANTHEM
4351567OtherAETNA
000000006713OtherM PLAN
INP00786840OtherR.R. MEDICARE
IN200092670Medicaid
IN000000637485OtherANTHEM
C24505Medicare UPIN
IN100108770AMedicaid