Healthcare Provider Details

I. General information

NPI: 1134588445
Provider Name (Legal Business Name): GERROD SMITH SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 OLD HIGHWAY 33
LANGSTON OK
73050-0465
US

IV. Provider business mailing address

PO BOX 465
LANGSTON OK
73050-0465
US

V. Phone/Fax

Practice location:
  • Phone: 405-332-8001
  • Fax:
Mailing address:
  • Phone: 405-332-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: