Provider Demographics
NPI:1023029311
Name:SMITH, STEPHEN TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TYLER
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-0040
Mailing Address - Country:US
Mailing Address - Phone:580-243-0700
Mailing Address - Fax:580-243-0771
Practice Address - Street 1:2103 S MAIN ST STE N
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-9167
Practice Address - Country:US
Practice Address - Phone:580-243-0700
Practice Address - Fax:580-243-0771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3743111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK245529301Medicare UPIN