Healthcare Provider Details

I. General information

NPI: 1407350580
Provider Name (Legal Business Name): HEATH ADAM SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 US HIGHWAY 59
GROVE OK
74344-4229
US

IV. Provider business mailing address

PO BOX 863
JAY OK
74346-0863
US

V. Phone/Fax

Practice location:
  • Phone: 918-787-2242
  • Fax: 918-786-5985
Mailing address:
  • Phone: 918-253-7359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: