Provider Demographics
NPI:1962488585
Name:SMITH, RUSSEL DONNAN (MD)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:DONNAN
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 1:3567 NE TILLAMOOK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5158
Mailing Address - Country:US
Mailing Address - Phone:773-810-9072
Mailing Address - Fax:
Practice Address - Street 1:3567 NE TILLAMOOK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5158
Practice Address - Country:US
Practice Address - Phone:773-810-9072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050121992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00861014Medicaid
C49891Medicare UPIN
RB6580Medicare PIN