Provider Demographics
NPI:1770688178
Name:KOVACICH-SMITH, KATIE JO (DPM)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:JO
Last Name:KOVACICH-SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:JO
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:391 STAGECOACH LN
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:MT
Mailing Address - Zip Code:59644-9686
Mailing Address - Country:US
Mailing Address - Phone:406-266-3825
Mailing Address - Fax:
Practice Address - Street 1:1892 WILLIAMS STREET
Practice Address - Street 2:FORT HARRISON VAMC
Practice Address - City:FORT HARRISION
Practice Address - State:MT
Practice Address - Zip Code:59636
Practice Address - Country:US
Practice Address - Phone:406-447-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY118213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYU84723Medicare UPIN