Provider Demographics
NPI:1386630895
Name:SMITH, KEVIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
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:PO BOX 1946
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92312-1946
Mailing Address - Country:US
Mailing Address - Phone:760-255-2400
Mailing Address - Fax:760-588-4990
Practice Address - Street 1:525 MELISSA AVE STE A
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3002
Practice Address - Country:US
Practice Address - Phone:760-255-2400
Practice Address - Fax:760-588-4990
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAG77804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G778041Medicaid
CA00G778040Medicare PIN
CA00G778042Medicare PIN
CA00G778041Medicaid