Provider Demographics
NPI:1326026212
Name:SMITH, RICHARD BRENT (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRENT
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 1:4411 W GORE BLVD
Mailing Address - Street 2:SUITE B5
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5977
Mailing Address - Country:US
Mailing Address - Phone:580-357-0493
Mailing Address - Fax:
Practice Address - Street 1:4411 W GORE BLVD
Practice Address - Street 2:SUITE B5
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5977
Practice Address - Country:US
Practice Address - Phone:580-357-0493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE09967Medicare UPIN
OKOK700581Medicare PIN