Provider Demographics
NPI:1205875341
Name:SMITH, KWENDE (DPM)
Entity type:Individual
Prefix:
First Name:KWENDE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
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 2200
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-4200
Mailing Address - Country:US
Mailing Address - Phone:603-673-9411
Mailing Address - Fax:603-673-9899
Practice Address - Street 1:10 RESEARCH PL
Practice Address - Street 2:SUITE 206
Practice Address - City:NORTH CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01863-2439
Practice Address - Country:US
Practice Address - Phone:978-275-1390
Practice Address - Fax:978-275-1394
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2302213E00000X
NH0312213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0708437Medicaid
MA27-01376OtherEVERCARE
MA94141OtherFALLON COMMUNITY HEALTH
MAY71125OtherBLUE CROSS BLUE SHIELD
MAY71125OtherBLUE CROSS BLUE SHIELD
MA94141OtherFALLON COMMUNITY HEALTH
MA0708437Medicaid