Provider Demographics
NPI:1235291139
Name:SMITH, KEN ROGERS (MD)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:ROGERS
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 1:6918 WASHITA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78256-2306
Mailing Address - Country:US
Mailing Address - Phone:210-257-9134
Mailing Address - Fax:
Practice Address - Street 1:4241 WOODCOCK DR
Practice Address - Street 2:SUITE A-100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1328
Practice Address - Country:US
Practice Address - Phone:210-785-5200
Practice Address - Fax:210-785-5389
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08438207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F20593Medicare PIN