Provider Demographics
NPI:1831137041
Name:SMITH, CHARLES D (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
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 1:740 S LIMESTONE
Mailing Address - Street 2:J 401
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:J 401
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0284
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY254442084N0400X, 2085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64254444Medicaid
KY64254444Medicaid
0054490Medicare ID - Type Unspecified