Provider Demographics
NPI:1669440772
Name:SMITH, RUSSELL M (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
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 1:16506 SW 29TH STREET APT K93
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:509-493-1101
Mailing Address - Fax:
Practice Address - Street 1:211 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:509-493-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029546207P00000X
ORMD14453207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8117327Medicaid
OR105593Medicaid
NV2081666Medicaid
CAXPY196668Medicaid
CAXPY196668Medicaid
OR105593Medicaid
NV2081666Medicaid