Provider Demographics
NPI:1457690885
Name:SMITH, KELLY ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4255
Mailing Address - Country:US
Mailing Address - Phone:607-723-9018
Mailing Address - Fax:
Practice Address - Street 1:134 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4255
Practice Address - Country:US
Practice Address - Phone:607-723-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006711-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery