Provider Demographics
NPI:1972583607
Name:SMITH, CARL EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:EDWIN
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:120 PROFESSIONAL LANE
Mailing Address - Street 2:STE 201
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2603
Mailing Address - Country:US
Mailing Address - Phone:606-573-1004
Mailing Address - Fax:606-573-0059
Practice Address - Street 1:120 PROFESSIONAL LANE
Practice Address - Street 2:STE 201
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2603
Practice Address - Country:US
Practice Address - Phone:606-573-1004
Practice Address - Fax:606-573-0059
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY24028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000953Medicaid
KY31000953Medicaid
KY9719Medicare ID - Type Unspecified