1245401058 NPI number — STEVE L SMITH OD PROFESSIONAL CORPORATION

Table of content: (NPI 1245401058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245401058 NPI number — STEVE L SMITH OD PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVE L SMITH OD PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PRIMARY EYE CARE ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1245401058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 E BLUE STARR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAREMORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74017-4223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-341-8211
Provider Business Mailing Address Fax Number:
918-341-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 E BLUE STARR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74017-4223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-341-8211
Provider Business Practice Location Address Fax Number:
918-341-8233
Provider Enumeration Date:
03/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CRISSUP
Authorized Official First Name:
LACY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
918-341-8211

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  870 , 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: 100761360A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com