Provider Demographics
NPI:1306361076
Name:SMITH, TIMOTHY MICHAEL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:DALE
Mailing Address - State:OK
Mailing Address - Zip Code:74851-8222
Mailing Address - Country:US
Mailing Address - Phone:805-901-7119
Mailing Address - Fax:
Practice Address - Street 1:101 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:DALE
Practice Address - State:OK
Practice Address - Zip Code:74851-8222
Practice Address - Country:US
Practice Address - Phone:805-901-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty