Provider Demographics
NPI:1699217091
Name:SMITH, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2601
Mailing Address - Country:US
Mailing Address - Phone:918-273-1841
Mailing Address - Fax:918-273-1843
Practice Address - Street 1:17599 S HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-0801
Practice Address - Country:US
Practice Address - Phone:918-342-0770
Practice Address - Fax:918-341-4245
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist