Provider Demographics
NPI:1518048735
Name:SMITH-HAXTON, SERESE YVONNE (MD)
Entity Type:Individual
Prefix:
First Name:SERESE
Middle Name:YVONNE
Last Name:SMITH-HAXTON
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 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-632-5510
Mailing Address - Fax:573-632-5810
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-632-5510
Practice Address - Fax:573-632-5810
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 04-31151207V00000X
MO2009035426207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518048735Medicaid
KS100447000DMedicaid
MO991295001Medicare PIN
MO1518048735Medicaid