Provider Demographics
NPI:1588720973
Name:SMITH, KIMBERLY IVY (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:IVY
Last Name:SMITH
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 1:178 LASALLE LEFALL DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-5278
Mailing Address - Country:US
Mailing Address - Phone:850-875-3600
Mailing Address - Fax:850-627-7277
Practice Address - Street 1:178 LASALLE LEFALL DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-5278
Practice Address - Country:US
Practice Address - Phone:850-875-3600
Practice Address - Fax:850-627-7277
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201205340Medicaid
IN201205340Medicaid