Basic Information
| Provider Information | |||||||||
| NPI: | 1396916219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 SCOTT BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300335645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789044932 | ||||||||
| FaxNumber: | 4704282869 | ||||||||
| Practice Location | |||||||||
| Address1: | 1670 SCOTT BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300335645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789044932 | ||||||||
| FaxNumber: | 4704282869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 053035 | GA | N | Allopathic & Osteopathic Physicians | Dermatology | 207ZD0900X | 053035 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZI0100X | 053035 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Immunopathology |
ID Information
| ID | Type | State | Issuer | Description | 090074158A | 05 | GA | MEDICAID | 460052 | 01 | GA | WELLCARE | OTHER |