Provider Demographics
NPI:1740209170
Name:SMITH, GLENN L (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
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 1:2149 SW 59TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-7033
Mailing Address - Country:US
Mailing Address - Phone:405-682-4651
Mailing Address - Fax:405-682-3391
Practice Address - Street 1:2149 SW 59TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-7033
Practice Address - Country:US
Practice Address - Phone:405-682-4651
Practice Address - Fax:405-682-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1667174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731079803OtherFEDERAL TAX ID #
OK731079803001OtherBLUE CROSS BLUE SHIELD
OK731079803OtherFEDERAL TAX ID #
OK242414002Medicare ID - Type Unspecified