Provider Demographics
NPI:1427019868
Name:SMITH, GAVIN HALL (DPM)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:HALL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:7308 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2777
Practice Address - Country:US
Practice Address - Phone:253-582-7257
Practice Address - Fax:253-582-0687
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000791213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00245950OtherRAILROAD MEDICARE BILLING
WA8431215Medicaid
WACJ4574OtherRAILROAD MEDICARE
WA8855255Medicare PIN
WACJ4574OtherRAILROAD MEDICARE
UTV02082Medicare UPIN
WA8855254Medicare PIN
WAP00245950OtherRAILROAD MEDICARE BILLING