Provider Demographics
NPI:1639517592
Name:SMITH, CHARLES L (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59390 E 288 CT
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7735
Mailing Address - Country:US
Mailing Address - Phone:918-787-9997
Mailing Address - Fax:
Practice Address - Street 1:59390 E 288 CT
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7735
Practice Address - Country:US
Practice Address - Phone:918-787-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine