Provider Demographics
NPI:1346350352
Name:SMALLWOOD, KRISTIN WIDICK (MD)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:WIDICK
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1980 N ATLANTIC AVE
Mailing Address - Street 2:SUITE 722
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5213
Mailing Address - Country:US
Mailing Address - Phone:321-784-8811
Mailing Address - Fax:321-799-4424
Practice Address - Street 1:1980 N ATLANTIC AVE
Practice Address - Street 2:SUITE 722
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5213
Practice Address - Country:US
Practice Address - Phone:321-784-8811
Practice Address - Fax:321-799-4424
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0056367207N00000X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08903ZMedicare ID - Type Unspecified
FLE75811Medicare UPIN