Provider Demographics
NPI:1194727685
Name:SMITH, RAYMOND W (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-7300
Mailing Address - Country:US
Mailing Address - Phone:580-208-3159
Mailing Address - Fax:
Practice Address - Street 1:1301 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7300
Practice Address - Country:US
Practice Address - Phone:580-208-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4248342085R0202X
OK242082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100165840BMedicaid
KS104513Medicare ID - Type Unspecified
KS100165840BMedicaid