Provider Demographics
NPI:1114118700
Name:SMITH, MARY LEANN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LEANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 NW 31ST ST
Mailing Address - Street 2:OKCC L100
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6100
Mailing Address - Country:US
Mailing Address - Phone:580-536-2121
Mailing Address - Fax:580-536-2121
Practice Address - Street 1:800 NE 10TH ST
Practice Address - Street 2:OKCC L100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5418
Practice Address - Country:US
Practice Address - Phone:405-271-3021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25797207R00000X, 207UN0902X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy