Provider Demographics
NPI:1962859843
Name:SMITH, LEE KASIM
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:KASIM
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TEAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-8501
Mailing Address - Country:US
Mailing Address - Phone:270-872-9338
Mailing Address - Fax:
Practice Address - Street 1:10625 NSH
Practice Address - Street 2:CAMPUS BOX #7160
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-7160
Practice Address - Country:US
Practice Address - Phone:984-974-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC219207390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program