Healthcare Provider Details

I. General information

NPI: 1427207364
Provider Name (Legal Business Name): LISA J WASEMILLER-SMITH MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 N PORTLAND AVE
OKLAHOMA CITY OK
73120-5045
US

IV. Provider business mailing address

11200 N PORTLAND AVE
OKLAHOMA CITY OK
73120-5045
US

V. Phone/Fax

Practice location:
  • Phone: 405-936-1100
  • Fax: 405-936-1122
Mailing address:
  • Phone: 405-936-1100
  • Fax: 405-936-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13137
License Number StateOK

VIII. Authorized Official

Name: LISA WASEMILLER-SMITH
Title or Position: OWNER
Credential: M.D.
Phone: 405-936-1100