Basic Information
| Provider Information | |||||||||
| NPI: | 1144269960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603971500 | ||||||||
| FaxNumber: | 3603973128 | ||||||||
| Practice Location | |||||||||
| Address1: | 2005 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BATTLE GROUND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986044311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603974060 | ||||||||
| FaxNumber: | 3606664772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD11631 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MD00046149 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | MD00046149 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8948203 | 01 | WA | L & I CRIME VICTIMS | OTHER | 026808 | 05 | OR | MEDICAID | 0238840 | 01 | WA | L & I | OTHER | 8518334 | 05 | WA | MEDICAID | P00360925 | 01 | OR | RR MEDICARE | OTHER |