Provider Demographics
NPI:1649226895
Name:SMITH, PAUL E III (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:SMITH
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FONTAINE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-9216
Mailing Address - Country:US
Mailing Address - Phone:231-742-1213
Mailing Address - Fax:
Practice Address - Street 1:1550 HIGHWAY 15 S STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-0714
Practice Address - Country:US
Practice Address - Phone:606-666-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03402207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPS012921OtherBLUE CROSS
KY7100177400Medicaid
MI114947926Medicaid
MIPS012921OtherBLUE CROSS
KY7100177400Medicaid
MIF52011Medicare UPIN