Provider Demographics
NPI:1093732562
Name:SMITH, MALCOLM DEREK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:DEREK
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2762
Mailing Address - Country:US
Mailing Address - Phone:580-765-3389
Mailing Address - Fax:580-762-3994
Practice Address - Street 1:1700 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2762
Practice Address - Country:US
Practice Address - Phone:580-765-3389
Practice Address - Fax:580-762-3994
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK198213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779800AMedicaid
U71325Medicare UPIN
OK0607390002Medicare NSC
OK$$$$$$$$$PMedicare PIN