Provider Demographics
NPI:1982606927
Name:SMITH, KEVIN DENNIS (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DENNIS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 VALLEY VIEW DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-7919
Mailing Address - Fax:309-762-3261
Practice Address - Street 1:505 VALLEY VIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-7919
Practice Address - Fax:309-762-3261
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-4863213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU79400Medicare UPIN
ILK44884Medicare PIN
P00007495Medicare PIN