Provider Demographics
NPI:1376980656
Name:SMITH, BILLY
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:
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 1:34396 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:OK
Mailing Address - Zip Code:74577-1019
Mailing Address - Country:US
Mailing Address - Phone:918-647-6216
Mailing Address - Fax:
Practice Address - Street 1:34396 RIVER RD
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:OK
Practice Address - Zip Code:74577-1019
Practice Address - Country:US
Practice Address - Phone:918-647-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator