Basic Information
| Provider Information | |||||||||
| NPI: | 1366437246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITHTON | ||||||||
| FirstName: | CORBY | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055331474 | ||||||||
| FaxNumber: | 4057424990 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055331474 | ||||||||
| FaxNumber: | 4057424990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 07/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3789 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100119580A | 05 | OK | MEDICAID |