Provider Demographics
NPI:1265239131
Name:SMITH, MATTIAS WADE
Entity type:Individual
Prefix:
First Name:MATTIAS
Middle Name:WADE
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72C CENTENNIAL LOOP STE 100
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2453
Mailing Address - Country:US
Mailing Address - Phone:541-972-1824
Mailing Address - Fax:
Practice Address - Street 1:72C CENTENNIAL LOOP STE 100
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2453
Practice Address - Country:US
Practice Address - Phone:541-972-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR105411175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist