Basic Information
| Provider Information | |||||||||
| NPI: | 1184675860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5645 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730835645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054706767 | ||||||||
| FaxNumber: | 4054706768 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 RENAISSANCE BLVD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054706767 | ||||||||
| FaxNumber: | 4054706768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 14140 | OK | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 174400000X | 14140 | OK | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100826770B | 05 | OK | MEDICAID |