Healthcare Provider Details

I. General information

NPI: 1457357972
Provider Name (Legal Business Name): TIM K SMALLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 N HIGHWAY 102
MCLOUD OK
74851
US

IV. Provider business mailing address

PO BOX 1360
MCLOUD OK
74851-1360
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-2081
  • Fax: 405-964-2053
Mailing address:
  • Phone: 405-964-2081
  • Fax: 405-964-2053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8274
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: