Provider Demographics
NPI:1790847952
Name:SMITH, KEVIN KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:KIMBERLY
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 1:1550 S PIONEER WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4637
Mailing Address - Country:US
Mailing Address - Phone:509-765-6525
Mailing Address - Fax:
Practice Address - Street 1:1550 S PIONEER WAY STE 100
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4637
Practice Address - Country:US
Practice Address - Phone:509-765-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023951207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF01973Medicare UPIN