Provider Demographics
NPI:1093120933
Name:SMITH, CLIFFORD C III (DO)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:C
Last Name:SMITH
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1348
Mailing Address - Country:US
Mailing Address - Phone:859-404-7686
Mailing Address - Fax:859-274-4459
Practice Address - Street 1:44 WATER ST
Practice Address - Street 2:
Practice Address - City:OWINGSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40360-8944
Practice Address - Country:US
Practice Address - Phone:606-674-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP941207Q00000X
390200000X
KY04144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100464740Medicaid