Provider Demographics
NPI:1952541203
Name:SMITH, AMANDA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:211 FOUNTAIN CT STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2695
Practice Address - Country:US
Practice Address - Phone:859-629-7245
Practice Address - Fax:859-629-7246
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45030208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000848561 (KOHMG)OtherANTHEM BC/BS
KY7100165640 (KOHMG)Medicaid
KYK055473 (KOHMG)Medicare PIN