Provider Demographics
NPI:1447489638
Name:SMITH, KRYSTAL S (DO)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 KRAFT RD STE 350
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-5037
Mailing Address - Country:US
Mailing Address - Phone:239-238-1210
Mailing Address - Fax:239-238-1212
Practice Address - Street 1:3555 KRAFT RD STE 350
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34105-5037
Practice Address - Country:US
Practice Address - Phone:239-238-1210
Practice Address - Fax:239-238-1212
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-22462085R0202X
ALMDDO15782085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01590545OtherRAILROAD MEDICARE
MS05409055Medicaid
MS306502YKDBMedicare PIN
MS05409055Medicaid