Provider Demographics
NPI:1629050364
Name:SMITH, WILLIAM KEITH SR (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KEITH
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779540AMedicaid
OKP01598909OtherRAILROAD MEDICARE
OKT40772Medicare UPIN
OK467075ZSR2Medicare PIN