MEDICARE: DR. MALCOLM DEREK SMITH DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	198	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093732562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALCOLM DEREK SMITH DPM

Provider Business Mailing Address
First Line	:	1700 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2762
Country	:	US
Telephone Number	:	580-765-3389
Fax Number	:	580-762-3994

Provider Business Practice Location Address
First Line	:	1700 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2762
Country	:	US
Telephone Number	:	580-765-3389
Fax Number	:	580-762-3994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	04/22/2008

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