Provider Demographics
NPI:1669465811
Name:SMITHSON, JOHN R JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SMITHSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 NEO LOOP
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6046
Mailing Address - Country:US
Mailing Address - Phone:918-786-9568
Mailing Address - Fax:918-293-3116
Practice Address - Street 1:1120 NEO LOOP
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-6046
Practice Address - Country:US
Practice Address - Phone:918-786-9568
Practice Address - Fax:918-293-3116
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11399207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088280AMedicaid
OKD42842Medicare UPIN
OK248719110Medicare PIN