Provider Demographics
NPI:1639836398
Name:SMITH, SAMUEL OKLEY
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OKLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3014 PAPA BEAR DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-1402
Mailing Address - Country:US
Mailing Address - Phone:361-212-0849
Mailing Address - Fax:
Practice Address - Street 1:400 BIZZELL ST
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77843-0001
Practice Address - Country:US
Practice Address - Phone:979-845-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer