Provider Demographics
NPI:1285725937
Name:SMITH, KENNETH PAUL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:SMITH
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:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-0951
Mailing Address - Country:US
Mailing Address - Phone:209-617-3721
Mailing Address - Fax:209-966-8438
Practice Address - Street 1:5189 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9524
Practice Address - Country:US
Practice Address - Phone:209-966-3631
Practice Address - Fax:209-966-8438
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68554207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE69389Medicare UPIN
CAAO927ZMedicare PIN
CAAO927YMedicare PIN