Provider Demographics
NPI:1235363839
Name:SMITH, BENJAMIN EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:3135 ZION RD
Practice Address - Street 2:SUITE B
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-9204
Practice Address - Country:US
Practice Address - Phone:270-826-9444
Practice Address - Fax:270-826-9002
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03631208VP0000X, 208VP0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300001647Medicaid
KY7100249310Medicaid
KY03631OtherLICENSE
IN300001647Medicaid
KYK107662Medicare UPIN