Provider Demographics
NPI:1114118643
Name:SMITH, BRIAN LEE (PRESIDENT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6718 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1807
Mailing Address - Country:US
Mailing Address - Phone:405-602-1053
Mailing Address - Fax:405-602-1059
Practice Address - Street 1:6718 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1807
Practice Address - Country:US
Practice Address - Phone:405-602-1053
Practice Address - Fax:405-602-1059
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24186174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty