Provider Demographics
NPI:1548243199
Name:SMITH, BRYAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
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 1:825 SE BISHOP BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:509-332-3488
Mailing Address - Fax:
Practice Address - Street 1:825 SE BISHOP BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5517
Practice Address - Country:US
Practice Address - Phone:509-332-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73728208800000X
ORMD28964208800000X
WAMD00049274208800000X
IDM12316208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8519233Medicaid
WA8948199OtherL & I CRIME VICTIMS
WA0238521OtherL & I
WAG8874857Medicare PIN