Provider Demographics
NPI:1740933670
Name:SMITH, MICAH (RD)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 S SOONER RD APT 36203
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-2724
Mailing Address - Country:US
Mailing Address - Phone:405-209-3449
Mailing Address - Fax:
Practice Address - Street 1:6929 S SOONER RD APT 36203
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2724
Practice Address - Country:US
Practice Address - Phone:405-209-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2656133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered