Provider Demographics
NPI:1679985311
Name:SMITH, KEIRSTEN E (MD)
Entity type:Individual
Prefix:MRS
First Name:KEIRSTEN
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEIRSTEN
Other - Middle Name:
Other - Last Name:DAVIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:145 4TH AVE NE
Mailing Address - Street 2:FAMILY PRACTICE/ SPORTS MEDICINE
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837
Mailing Address - Country:US
Mailing Address - Phone:906-428-3273
Mailing Address - Fax:906-428-1881
Practice Address - Street 1:145 4TH AVE NE
Practice Address - Street 2:FAMILY PRACTICE/ SPORTS MEDICINE
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837
Practice Address - Country:US
Practice Address - Phone:906-428-3273
Practice Address - Fax:906-428-1881
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD36202207Q00000X
ALL4014R207Q00000X
MI4301116666207Q00000X
390200000X
MI430111666207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1679985311Medicaid