Provider Demographics
NPI:1871567578
Name:SMITH, MICHELLE DEANN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DEANN
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 1:102 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1961
Mailing Address - Country:US
Mailing Address - Phone:270-707-2100
Mailing Address - Fax:270-707-2103
Practice Address - Street 1:227 BURLEY AVE
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8725
Practice Address - Country:US
Practice Address - Phone:270-887-5640
Practice Address - Fax:270-886-5371
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26593207NS0135X
KY54389207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC265938Medicaid
SC8421Medicare PIN
SCL34878Medicare UPIN
SC265938Medicaid