Provider Demographics
NPI:1780677419
Name:WALLSMITH, CHRISTIE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:WALLSMITH
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 1:3808 N WILLIAMS AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1467
Mailing Address - Country:US
Mailing Address - Phone:503-970-2056
Mailing Address - Fax:888-432-4730
Practice Address - Street 1:3808 N WILLIAMS AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1467
Practice Address - Country:US
Practice Address - Phone:503-970-2056
Practice Address - Fax:888-432-4730
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1772208000000X
ORMD27140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics