Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207U00000X | Nuclear Medicine Specialist | OS2395 | FL |
NPI | 1043250061 |
---|---|
Provider Name | Kenneth Smith |
First Address | Belleview, FL 34420-3805 |
Second Address | Belleview, FL 34420-4025 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2006 |
Last Update Date | 02/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
061818701 | (05) | FL |
82045 | BLUE CROSS BLUE SHIELD OF FLORIDA (01) | FL |
E56740 | (02) | FL |