Provider Demographics
NPI:1760431209
Name:SMITH, KENNETH JR (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SMITH
Suffix:JR
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 1:123 WILLOW OAK LANE
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062
Mailing Address - Country:US
Mailing Address - Phone:856-220-0630
Mailing Address - Fax:
Practice Address - Street 1:123 WILLOW OAK LANE
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062
Practice Address - Country:US
Practice Address - Phone:856-237-4126
Practice Address - Fax:856-417-3089
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB66187207RC0200X, 207RC0200X
NJ25MB06618700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G866968Medicare UPIN