Provider Demographics
NPI:1609872860
Name:SMITH, KENNETH LAMONT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LAMONT
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 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:859-572-3617
Mailing Address - Fax:859-572-2326
Practice Address - Street 1:8251 PINE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2191
Practice Address - Country:US
Practice Address - Phone:833-781-7611
Practice Address - Fax:859-572-2326
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19102207P00000X
OH35050367207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0563091Medicaid
IN100328930Medicaid
KY64191026Medicaid
KY64191026Medicaid
IN100328930Medicaid
KY3313120Medicare PIN
C64135Medicare UPIN
KY3396280Medicare PIN
KY0655064Medicare PIN
OH0654353Medicare PIN