Provider Demographics
NPI:1891775185
Name:ONEIL-SMITH, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ONEIL-SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:ONEIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:380 PLEASANT ST
Mailing Address - Street 2:STE 13
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:781-322-3005
Mailing Address - Fax:781-322-1394
Practice Address - Street 1:380 PLEASANT ST
Practice Address - Street 2:STE 13
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148
Practice Address - Country:US
Practice Address - Phone:781-322-3005
Practice Address - Fax:781-322-1394
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0116891Medicaid
H46193Medicare UPIN
MA0116891Medicaid