Provider Demographics
NPI:1790791374
Name:SMITH, MARIAN ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:CR110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8051
Mailing Address - Fax:503-494-1310
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:CR110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8051
Practice Address - Fax:503-494-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I30490Medicare UPIN