Provider Demographics
NPI:1871535831
Name:SMITH, OLIVER ROY JR (DC)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:ROY
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:OLIVER
Other - Middle Name:ROY
Other - Last Name:SMITH
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1417 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4752
Mailing Address - Country:US
Mailing Address - Phone:915-533-2225
Mailing Address - Fax:915-533-0974
Practice Address - Street 1:1417 N BROWN ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4752
Practice Address - Country:US
Practice Address - Phone:915-533-2225
Practice Address - Fax:915-533-0974
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB06007148Medicaid
TXB06007148Medicaid
TX600714Medicare ID - Type Unspecified