Provider Demographics
NPI:1780918540
Name:SMITH, KRISTEN DIANE (MD)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:DIANE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:DIANE
Other - Last Name:MCCORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:2100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5487
Practice Address - Country:US
Practice Address - Phone:815-725-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01096117A208000000X, 208M00000X
IL125-055924208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130223Medicaid