Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 107833 | MO |
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 25369 | OK |
NPI | 1043371198 |
---|---|
Provider Name | Dr. Courtland Prentice Smith JR. |
First Address | Afton, OK 74331 |
Second Address | Afton, OK 74331 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 05/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
128329001 | (05) | AR |
19859 | BLUE CROSS BLUE SHIELD (01) | MO |
207948209 | (05) | MO |
97588 | BLUE CROSS BLUE SHIELD (01) | AR |
C67248 | (02) | MO |