Provider Demographics
NPI:1619969904
Name:SMITH, DWAYNE V (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:V
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 1:4900 HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-4824
Mailing Address - Country:US
Mailing Address - Phone:859-212-4625
Mailing Address - Fax:859-212-4638
Practice Address - Street 1:4900 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4824
Practice Address - Country:US
Practice Address - Phone:859-212-4625
Practice Address - Fax:859-212-4638
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23626208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01134522OtherRR MEDICARE
IN200347010AMedicaid
KY020049483OtherRAILROAD MEDICARE
KY64236268Medicaid
OH2626582Medicaid
KYP01134522OtherRR MEDICARE
OH4131001Medicare PIN
C69334Medicare UPIN
IN200347010AMedicaid
KY3400134Medicare PIN
KYK006950Medicare PIN
KY020049483OtherRAILROAD MEDICARE