Provider Demographics
NPI:1881892552
Name:SMASH, KIMBERLY MCCULLOUGH (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MCCULLOUGH
Last Name:SMASH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANITRA
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1020
Mailing Address - Country:US
Mailing Address - Phone:601-718-0308
Mailing Address - Fax:855-838-7032
Practice Address - Street 1:2675 RIVER RIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-718-0308
Practice Address - Fax:855-838-7032
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-04
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090322207Q00000X
MS21233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine