Provider Demographics
NPI:1306896931
Name:SMITH, KEVIN L (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:605 S ENOTA DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2437
Mailing Address - Country:US
Mailing Address - Phone:770-538-0208
Mailing Address - Fax:770-538-0556
Practice Address - Street 1:605 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2437
Practice Address - Country:US
Practice Address - Phone:770-538-0208
Practice Address - Fax:770-538-0556
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038371207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0005756529OtherAETNA
GA1306896931OtherBCBS
GA070011202OtherRAILROAD MEDICARE
GA000678983BMedicaid
GACH9982OtherRAILROAD MEDICARE
GA000678983BMedicaid
GACH9982OtherRAILROAD MEDICARE
GAGRP3402Medicare PIN