Basic Information
| Provider Information | |||||||||
| NPI: | 1093120933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 236 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8592744459 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 WATER ST | ||||||||
| Address2: | |||||||||
| City: | OWINGSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403608944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066749708 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2014 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TP941 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 04144 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100464740 | 05 | KY | MEDICAID |