Provider Demographics
NPI:1780417329
Name:SMITH, KITWAN
Entity type:Individual
Prefix:
First Name:KITWAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 POLARIS PKWY APT 316
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-2406
Mailing Address - Country:US
Mailing Address - Phone:614-886-1501
Mailing Address - Fax:
Practice Address - Street 1:801 POLARIS PKWY APT 316
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-2406
Practice Address - Country:US
Practice Address - Phone:614-886-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker