Provider Demographics
NPI:1558340554
Name:SMITH, EILEEN PAZDERKA (MD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:PAZDERKA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 W BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2935
Mailing Address - Country:US
Mailing Address - Phone:509-525-9404
Mailing Address - Fax:509-525-9433
Practice Address - Street 1:228 W BIRCH ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2935
Practice Address - Country:US
Practice Address - Phone:509-525-9404
Practice Address - Fax:509-525-9433
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035233174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6263030001Medicare NSC
8857674Medicare PIN
G52453Medicare UPIN