Provider Demographics
NPI:1316029077
Name:SMITH, KENNETH RONALD (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RONALD
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 1:8991 REDDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19933-4746
Mailing Address - Country:US
Mailing Address - Phone:302-337-3300
Mailing Address - Fax:302-337-8072
Practice Address - Street 1:8991 REDDEN RD
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:DE
Practice Address - Zip Code:19933-4746
Practice Address - Country:US
Practice Address - Phone:302-337-3300
Practice Address - Fax:302-337-8072
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10003941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000456901Medicaid
DEF37736Medicare UPIN
DE0000456901Medicaid
DE107990I16Medicare PIN