Basic Information
| Provider Information | |||||||||
| NPI: | 1043371198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | COURTLAND | ||||||||
| MiddleName: | PRENTICE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26300 SOUTH HWY 125 | ||||||||
| Address2: | |||||||||
| City: | AFTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182578585 | ||||||||
| FaxNumber: | 9182578560 | ||||||||
| Practice Location | |||||||||
| Address1: | 26300 SOUTH HWY 125 | ||||||||
| Address2: | |||||||||
| City: | AFTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182578585 | ||||||||
| FaxNumber: | 9182578560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 01/05/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 107833 | MO | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 25369 | OK | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 19859 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 207948209 | 05 | MO | MEDICAID | 128329001 | 05 | AR | MEDICAID | 97588 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER |