Healthcare Provider Details

I. General information

NPI: 1356361380
Provider Name (Legal Business Name): ROGER E. SMITH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4345 W MEMORIAL RD SUITE 110
OKLAHOMA CITY OK
73134-1702
US

IV. Provider business mailing address

4345 W MEMORIAL RD SUITE 110
OKLAHOMA CITY OK
73134-1702
US

V. Phone/Fax

Practice location:
  • Phone: 405-951-4160
  • Fax: 405-951-4162
Mailing address:
  • Phone: 405-951-4160
  • Fax: 405-951-4162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number28098
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: