Provider Demographics
NPI:1376676494
Name:SMITH PODIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:SMITH PODIATRIC SERVICES PLLC
Other - Org Name:AFFILIATED FOOT & ANKLE CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-275-8234
Mailing Address - Street 1:1627 N KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4313
Mailing Address - Country:US
Mailing Address - Phone:405-275-8234
Mailing Address - Fax:405-275-7298
Practice Address - Street 1:1627 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4313
Practice Address - Country:US
Practice Address - Phone:405-275-8234
Practice Address - Fax:405-275-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152213ES0103X
OK205213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522021Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
OK4371770001Medicare NSC