Provider Demographics
NPI:1285803049
Name:MALCOLM DEREK SMITH, DPM PC
Entity type:Organization
Organization Name:MALCOLM DEREK SMITH, DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-765-3389
Mailing Address - Street 1:1700 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2762
Mailing Address - Country:US
Mailing Address - Phone:580-765-3389
Mailing Address - Fax:580-762-3994
Practice Address - Street 1:1700 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2762
Practice Address - Country:US
Practice Address - Phone:580-765-3389
Practice Address - Fax:580-762-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK198213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100779800AMedicaid
OK294540038001OtherBLUE CROSS BLUE SHIELD
OK294540038PMedicare PIN
OKU71325Medicare UPIN
OK100779800AMedicaid