Provider Demographics
NPI:1992010896
Name:SMITH, KEVIN JON (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JON
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:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-1847
Mailing Address - Country:US
Mailing Address - Phone:480-507-2961
Mailing Address - Fax:480-507-2971
Practice Address - Street 1:428 S GILBERT RD STE 115
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2262
Practice Address - Country:US
Practice Address - Phone:480-507-2961
Practice Address - Fax:480-507-2971
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ48963207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ906314Medicaid
AZZ166243Medicare PIN