Provider Demographics
NPI:1871863258
Name:OKLAHOMA SENIOR PODIATRY SERVICES, P.C.
Entity Type:Organization
Organization Name:OKLAHOMA SENIOR PODIATRY SERVICES, P.C.
Other - Org Name:AGGEUS OKLAHOMA PODIATRY SERVICES, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:SR
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-216-5518
Mailing Address - Street 1:10 S RIVERSIDE PLZ
Mailing Address - Street 2:STE 19 EAST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3728
Mailing Address - Country:US
Mailing Address - Phone:773-770-0140
Mailing Address - Fax:312-277-6757
Practice Address - Street 1:3208 BRUSH CREEK RD.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-1852
Practice Address - Country:US
Practice Address - Phone:866-216-5518
Practice Address - Fax:312-277-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200444490AMedicaid
OKOKA104262Medicare PIN