Provider Demographics
NPI:1306053707
Name:SPICKNALL, KERITH ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:KERITH
Middle Name:ELIZABETH
Last Name:SPICKNALL
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 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5505
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-474-7630
Practice Address - Fax:513-475-7636
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088164207N00000X, 207ND0900X
OH35093057207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2984043Medicaid
KY7100094580Medicaid
IN200962450Medicaid
KY7100094580Medicaid