Provider Demographics
NPI:1184675860
Name:SMITH, JEFFREY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5645
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-5645
Mailing Address - Country:US
Mailing Address - Phone:405-470-6767
Mailing Address - Fax:405-470-6768
Practice Address - Street 1:1800 RENAISSANCE BLVD
Practice Address - Street 2:STE 210
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3023
Practice Address - Country:US
Practice Address - Phone:405-470-6767
Practice Address - Fax:405-470-6768
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14140207VG0400X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100826770BMedicaid
OKE11710Medicare UPIN
OK100826770BMedicaid