Provider Demographics
NPI:1053561878
Name:R. BRENT SMITH, M.D., INC.
Entity type:Organization
Organization Name:R. BRENT SMITH, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-357-0493
Mailing Address - Street 1:4411 W GORE BLVD
Mailing Address - Street 2:STE. B-5
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5977
Mailing Address - Country:US
Mailing Address - Phone:580-357-0493
Mailing Address - Fax:580-248-6090
Practice Address - Street 1:4411 W GORE BLVD
Practice Address - Street 2:STE. B-5
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5977
Practice Address - Country:US
Practice Address - Phone:580-357-0493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5517Medicare PIN
OKE09967Medicare UPIN