Provider Demographics
NPI:1619948692
Name:SMALL, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:SMALL
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 757
Mailing Address - Street 2:
Mailing Address - City:CAMPTON
Mailing Address - State:KY
Mailing Address - Zip Code:41301-0757
Mailing Address - Country:US
Mailing Address - Phone:817-797-6767
Mailing Address - Fax:
Practice Address - Street 1:3802 KY-321
Practice Address - Street 2:
Practice Address - City:HAGGERHILL
Practice Address - State:KY
Practice Address - Zip Code:41222
Practice Address - Country:US
Practice Address - Phone:606-297-1644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21474207P00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000377498OtherBLUECROSS BLUESHIELD
WV1069188OtherBRICKSTREET
OH2624324Medicaid
KY64072978Medicaid
WV3810004017Medicaid
KY5490OtherMEDICARE GROUP
KY64072978Medicaid
KY000000377498OtherBLUECROSS BLUESHIELD
OH2624324Medicaid
KY0549029Medicare PIN