Provider Demographics
NPI:1104859040
Name:SMITH, KATRINA A (MD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 NE 23RD CT
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-9056
Mailing Address - Country:US
Mailing Address - Phone:715-581-5713
Mailing Address - Fax:515-630-0278
Practice Address - Street 1:2675 N ANKENY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4719
Practice Address - Country:US
Practice Address - Phone:515-217-4807
Practice Address - Fax:515-630-0278
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-42093207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000239350Medicare ID - Type Unspecified
WI34505700Medicaid
I09062Medicare UPIN