Provider Demographics
NPI:1356423420
Name:SMITH, KEVIN E (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
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 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:
Practice Address - Street 1:1931 TAMIAMI TRL STE 4-6
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2181
Practice Address - Country:US
Practice Address - Phone:941-888-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111943207Q00000X
IN01037258A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100379410Medicaid
INM400070575Medicare PIN
INBS2144498OtherDEA
INP00423209OtherRAILROAD INDIVIDUAL