1720074255 NPI number — TINA C SMALL MD

Table of content: TINA C SMALL MD (NPI 1720074255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720074255 NPI number — TINA C SMALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALL
Provider First Name:
TINA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEATY
Provider Other First Name:
TINA
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720074255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 WILSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SILL
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73503-4472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-558-8497
Provider Business Mailing Address Fax Number:
580-429-0819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SILL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73503-4472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-558-8497
Provider Business Practice Location Address Fax Number:
580-558-3323
Provider Enumeration Date:
09/20/2005

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: 208100000X , with the licence number:  24054 , 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: P00166228 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 487023200 . This is a "DOL" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200038730A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7664685 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".