Provider Demographics
NPI:1043371198
Name:SMITH, COURTLAND PRENTICE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTLAND
Middle Name:PRENTICE
Last Name:SMITH
Suffix:JR
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 1:26300 SOUTH HWY 125
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:OK
Mailing Address - Zip Code:74331
Mailing Address - Country:US
Mailing Address - Phone:918-257-8585
Mailing Address - Fax:918-257-8560
Practice Address - Street 1:26300 SOUTH HWY 125
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:OK
Practice Address - Zip Code:74331
Practice Address - Country:US
Practice Address - Phone:918-257-8585
Practice Address - Fax:918-257-8560
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107833207Y00000X
OK25369207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19859OtherBLUE CROSS BLUE SHIELD
MO207948209Medicaid
AR128329001Medicaid
AR97588OtherBLUE CROSS BLUE SHIELD
MO19859OtherBLUE CROSS BLUE SHIELD
MOC67248Medicare UPIN