Provider Demographics
NPI:1962067439
Name:SMITH, KENNETH GEORGE (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GEORGE
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 442
Mailing Address - Street 2:
Mailing Address - City:HIGH ROLLS MOUNTAIN PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0442
Mailing Address - Country:US
Mailing Address - Phone:575-682-1134
Mailing Address - Fax:
Practice Address - Street 1:26 APPLE VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:HIGH ROLLS
Practice Address - State:NM
Practice Address - Zip Code:88325
Practice Address - Country:US
Practice Address - Phone:575-632-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM73-70207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology