1265417687 NPI number — JENNIFER G SMITH MD

Table of content: JENNIFER G SMITH MD (NPI 1265417687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265417687 NPI number — JENNIFER G SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JENNIFER
Provider Middle Name:
G
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:
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:
1265417687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4140 W MEMORIAL RD
Provider Second Line Business Mailing Address:
SUITE 321
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120-8366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-748-4726
Provider Business Mailing Address Fax Number:
405-607-8497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4140 W MEMORIAL RD
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120-8366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-748-4726
Provider Business Practice Location Address Fax Number:
405-607-8497
Provider Enumeration Date:
12/08/2005

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: 207VM0101X , with the licence number:  28110 , 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: 80768 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10186714 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7959719 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200314200A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1391R . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: E4094 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".




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