Provider Demographics
NPI:1104961994
Name:SMILLIE, KENT (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:SMILLIE
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 1:787 37TH ST STE E200
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7306
Mailing Address - Country:US
Mailing Address - Phone:772-978-7808
Mailing Address - Fax:772-978-9320
Practice Address - Street 1:787 37TH ST STE E200
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7306
Practice Address - Country:US
Practice Address - Phone:772-978-7808
Practice Address - Fax:772-978-9320
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042627207X00000X
IN01068319A207X00000X
VA0101249094207X00000X
MEMD20796207X00000X
FLME130147207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200985030Medicaid
OR247586Medicaid
WA88545MOtherREGENCE
IN000000668941OtherANTHEM PROVIDER NUMBER
WA0176932OtherLABOR & INDUSTRIES
WA8931559OtherCRIME VICTIMS
FL019183400Medicaid
WA8379323Medicaid
FLIU736ZMedicare PIN
INM400016803Medicare PIN
WA0176932OtherLABOR & INDUSTRIES
OR247586Medicaid
WA88545MOtherREGENCE