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General NPI Number Information
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NPI Number | 1285803049
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Entity Type | Organization
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Legal Business Name | MALCOLM DEREK SMITH, DPM PC
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Dates
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Enumeration Date | 02/26/2008
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 1700 N 5TH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-2762
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Country | US
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Telephone | 580-765-3389
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Fax | 580-762-3994
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Provider Business Mailing Address
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Address Line | 1700 N 5TH ST
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City | PONCA CITY
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State | OK
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Zip | 74601-2762
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Country | US
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Telephone | 580-765-3389
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Fax | 580-762-3994
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER RAE SMITH
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Credential |
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Telephone | 580-765-3389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 198
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License Number State | OK
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