Provider Demographics
NPI:1427219567
Name:SMITH, DUSTIN JARED (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JARED
Last Name:SMITH
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9437
Practice Address - Country:US
Practice Address - Phone:503-215-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-0995207Q00000X
ORMD156439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01027050OtherRR MEDICARE (PROVIDENCE)
OR500640264Medicaid
ID808095300Medicaid
ORR163064Medicare PIN
ORR162851Medicare PIN
OR500640264Medicaid
ORR162854Medicare PIN
ORR162850Medicare PIN
ORR162853Medicare PIN
ORR167201Medicare PIN
ORR162852Medicare PIN
ORP01027050OtherRR MEDICARE (PROVIDENCE)