Provider Demographics
NPI:1134131907
Name:SMITH, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-465-3561
Mailing Address - Fax:
Practice Address - Street 1:125 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9634
Practice Address - Country:US
Practice Address - Phone:270-789-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30805207P00000X, 207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64308059Medicaid
KYF79234Medicare UPIN
KY0933214Medicare PIN