Healthcare Provider Details

I. General information

NPI: 1639866676
Provider Name (Legal Business Name): MELVIN MARCELL SMITH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 S WESTERN AVE
OKLAHOMA CITY OK
73139-1712
US

IV. Provider business mailing address

6510 S WESTERN AVE
OKLAHOMA CITY OK
73139-1712
US

V. Phone/Fax

Practice location:
  • Phone: 405-634-1497
  • Fax: 405-634-1919
Mailing address:
  • Phone: 405-634-1497
  • Fax: 405-634-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: