Provider Demographics
NPI:1497125215
Name:SMITH, KIRK LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:LANE
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 1:5460 PAREDES LINE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-9740
Mailing Address - Country:US
Mailing Address - Phone:956-554-0010
Mailing Address - Fax:956-554-3288
Practice Address - Street 1:5460 PAREDES LINE RD
Practice Address - Street 2:STE 200
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-9740
Practice Address - Country:US
Practice Address - Phone:956-554-0010
Practice Address - Fax:956-554-3288
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353601303Medicaid
TX461884YLPSOtherWELLMED PTAN