Provider Demographics
NPI:1023008653
Name:SMITH, KIRK M (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 SE MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-8705
Mailing Address - Country:US
Mailing Address - Phone:580-890-0545
Mailing Address - Fax:
Practice Address - Street 1:4909 SE MILLS AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-8705
Practice Address - Country:US
Practice Address - Phone:580-890-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23307207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019910AMedicaid
OK800522535OtherMEDICARE GROUP PIN
H25948Medicare UPIN
OK200019910AMedicaid