1447489638 NPI number — KRYSTAL S SMITH DO

Table of content: KRYSTAL S SMITH DO (NPI 1447489638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447489638 NPI number — KRYSTAL S SMITH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KRYSTAL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447489638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3555 KRAFT RD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34105-5037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-238-1210
Provider Business Mailing Address Fax Number:
239-238-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3555 KRAFT RD STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34105-5037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-238-1210
Provider Business Practice Location Address Fax Number:
239-238-1212
Provider Enumeration Date:
07/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  T-2246 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: MDDO1578 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01590545 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 05409055 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110569000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com