Provider Demographics
NPI:1780751099
Name:SMITH, KELLY DON (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DON
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 1:2200 N KIMBALL #700
Mailing Address - Street 2:PO BOX 975
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301
Mailing Address - Country:US
Mailing Address - Phone:605-996-1159
Mailing Address - Fax:605-996-1159
Practice Address - Street 1:2200 N KIMBALL #700
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301
Practice Address - Country:US
Practice Address - Phone:605-996-1159
Practice Address - Fax:605-996-1159
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD50122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7200660Medicaid
SD40152Medicare ID - Type Unspecified
SD7200660Medicaid