Provider Demographics
NPI:1578517314
Name:SMITH, KAREN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:SMITH
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 1:1431 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1735
Mailing Address - Country:US
Mailing Address - Phone:937-419-8687
Mailing Address - Fax:937-419-8688
Practice Address - Street 1:1431 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1735
Practice Address - Country:US
Practice Address - Phone:937-419-8687
Practice Address - Fax:937-419-8688
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2482586Medicaid
OH2482586Medicaid