Individual
MR. KENNETH A SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1234 EAST DUPONT ROAD, SUITE 5, FORT WAYNE, IN 46825
(260) 489-1666
(260) 489-3255
Mailing address
1234 EAST DUPONT ROAD, SUITE 1, FORT WAYNE, IN 46825
(260) 373-9728
(260) 459-5664
Taxonomy
Speciality
Code
Description
License number
State
207RR0500X
Rheumatology Physician
Primary
01022346
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000006713
M PLAN
—
01
—
000000206530
ANTHEM
—
01
—
000000637485
ANTHEM
IN
05
—
100108770A
—
IN
01
—
1866
PHP
—
05
—
200092670
—
IN
01
—
4351567
AETNA
—
01
—
P00786840
R.R. MEDICARE
IN
Enumeration date
09/28/2006
Last updated
08/03/2012
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