Provider Demographics
NPI:1093135741
Name:SMITH, KYLE CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:CHARLES
Last Name:SMITH
Suffix:
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 1:601 W SPRUCE ST STE J
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4047
Mailing Address - Country:US
Mailing Address - Phone:406-327-3350
Mailing Address - Fax:406-327-3355
Practice Address - Street 1:601 W SPRUCE ST STE J
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-327-3350
Practice Address - Fax:406-327-3355
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT666442084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty