Provider Demographics
NPI:1043265770
Name:SMALLEY, KENT RAGAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:RAGAN
Last Name:SMALLEY
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 1:3432 NW 178TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9150
Mailing Address - Country:US
Mailing Address - Phone:405-696-3773
Mailing Address - Fax:405-757-6953
Practice Address - Street 1:3432 NW 178TH ST STE A
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9150
Practice Address - Country:US
Practice Address - Phone:405-696-3773
Practice Address - Fax:405-757-6953
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK188602084A0401X, 2084B0040X, 2084P2900X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100094690AMedicaid
OK100094690AMedicaid