Provider Demographics
NPI:1316032931
Name:SMEAD, KENNETH WILSON III (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILSON
Last Name:SMEAD
Suffix:III
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 1:4 SHAWS CV STE 101
Mailing Address - Street 2:JOHN J. MCGUIRK VA OUTPATIENT CLINIC
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4956
Mailing Address - Country:US
Mailing Address - Phone:860-437-3611
Mailing Address - Fax:
Practice Address - Street 1:4 SHAWS CV STE 101
Practice Address - Street 2:JOHN J. MCGUIRK VA OUTPATIENT CLINIC
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4956
Practice Address - Country:US
Practice Address - Phone:860-437-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0408562083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine