Provider Demographics
NPI:1518244276
Name:SMITH, CHARLES G JR (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:G
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2843
Mailing Address - Country:US
Mailing Address - Phone:580-767-1961
Mailing Address - Fax:580-767-0749
Practice Address - Street 1:1209 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2843
Practice Address - Country:US
Practice Address - Phone:580-767-1961
Practice Address - Fax:580-767-0749
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK541237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist