Provider Demographics
NPI:1396916219
Name:SMITH, KATHLEEN JEANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JEANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 SCOTT BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5645
Mailing Address - Country:US
Mailing Address - Phone:678-904-4932
Mailing Address - Fax:470-428-2869
Practice Address - Street 1:1670 SCOTT BLVD STE 202
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5645
Practice Address - Country:US
Practice Address - Phone:678-904-4932
Practice Address - Fax:470-428-2869
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053035207N00000X, 207ZD0900X, 207ZI0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA090074158AMedicaid
GA460052OtherWELLCARE
GA202I224708Medicare PIN
GA090074158AMedicaid