Provider Demographics
NPI:1386619021
Name:SMITH, KENNETH R (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
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 1:9700 PARK PLAZA AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2286
Mailing Address - Country:US
Mailing Address - Phone:502-429-3937
Mailing Address - Fax:502-429-3996
Practice Address - Street 1:9700 PARK PLAZA AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2286
Practice Address - Country:US
Practice Address - Phone:502-429-3937
Practice Address - Fax:502-429-3996
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34564207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64435647Medicaid
KY0796801Medicare PIN
KY64435647Medicaid