Provider Demographics
NPI:1902805674
Name:SMITH, JOHN P (DO, FACOS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO, FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0905
Mailing Address - Country:US
Mailing Address - Phone:316-945-7309
Mailing Address - Fax:316-945-9131
Practice Address - Street 1:4013 N RIDGE RD
Practice Address - Street 2:STE 210
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-8860
Practice Address - Country:US
Practice Address - Phone:316-945-7309
Practice Address - Fax:316-945-9131
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-19194208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100189270AMedicaid
KSE53271Medicare UPIN
KS100189270AMedicaid