Provider Demographics
NPI:1184111643
Name:SMITH, KYLE (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
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 1:601 ELMWOOD AVE BOX 664
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-8394
Mailing Address - Fax:
Practice Address - Street 1:4901 LAC DE VILLE BLVD.
Practice Address - Street 2:BLDG D, SUITE 250
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5649
Practice Address - Country:US
Practice Address - Phone:585-275-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315062208100000X, 2084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program