Provider Demographics
NPI:1821030057
Name:SMART, KYLE N (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:N
Last Name:SMART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:16465 SIERRA LAKES PARKWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:909-429-2868
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:909-429-2868
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A8257207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX82570Medicaid
CAI43911Medicare UPIN
CA00AX82570Medicaid
020A82572Medicare PIN