Provider Demographics
NPI:1861574451
Name:SMART, JOHN ROBERT III (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:SMART
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:187 WOLFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3278
Mailing Address - Country:US
Mailing Address - Phone:606-787-6275
Mailing Address - Fax:606-787-0251
Practice Address - Street 1:187 WOLFORD AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3278
Practice Address - Country:US
Practice Address - Phone:606-787-6275
Practice Address - Fax:606-787-0251
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY02794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11554224OtherCAQH
KY64115041Medicaid
KY0732911Medicare ID - Type Unspecified
KYE32556Medicare UPIN