Provider Demographics
NPI:1043214471
Name:SMYTHE, MELANIE J (DO)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:J
Last Name:SMYTHE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 SE WOODSTOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6829
Mailing Address - Country:US
Mailing Address - Phone:503-236-1830
Mailing Address - Fax:844-896-9137
Practice Address - Street 1:5536 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6829
Practice Address - Country:US
Practice Address - Phone:503-236-1830
Practice Address - Fax:503-236-1908
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2019-10-10
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
ORDO19987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR081075Medicaid
OR081075Medicaid
R0000LGBVRMedicare ID - Type Unspecified