Provider Demographics
NPI:1306860424
Name:SMITH, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
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 1:78 SUNNYMEDE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2842
Mailing Address - Country:US
Mailing Address - Phone:859-331-6104
Mailing Address - Fax:
Practice Address - Street 1:78 SUNNYMEDE DR
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2842
Practice Address - Country:US
Practice Address - Phone:859-331-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21523207P00000X
OH35092296208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64215239Medicaid
OH0598367Medicaid
KY64215239Medicaid
KY231201Medicare PIN