1063474344 NPI number — LONNIE V. SMITH PA

Table of content: LONNIE V. SMITH PA (NPI 1063474344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063474344 NPI number — LONNIE V. SMITH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LONNIE
Provider Middle Name:
V.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063474344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2115 PARKVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL RENO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73036-2109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-295-1166
Provider Business Mailing Address Fax Number:
405-295-1334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 W MEMORIAL RD
Provider Second Line Business Practice Location Address:
ER DEPT.
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120-8304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-752-3715
Provider Business Practice Location Address Fax Number:
405-936-5058
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  698 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100117880B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100117880A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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