Healthcare Provider Details

I. General information

NPI: 1780028001
Provider Name (Legal Business Name): IAN MICHAEL SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 DEVON ST
STILLWATER OK
74074-1926
US

IV. Provider business mailing address

1442 E OAK ST
CUSHING OK
74023-3644
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-6100
  • Fax:
Mailing address:
  • Phone: 580-670-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10038
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: