Provider Demographics
NPI:1942396023
Name:SMITH, KENNETH R (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:6040 N 43RD AVE STE 1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-5481
Practice Address - Country:US
Practice Address - Phone:623-931-2221
Practice Address - Fax:623-934-2849
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2023-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ1718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0067790OtherBCBS
AZ259566Medicaid
AZAZ0067790OtherBCBS
AZAZ0067790OtherBCBS
AZE44482Medicare UPIN