Provider Demographics
NPI:1902166705
Name:SMITH, REBECCA NICOLE (REBECCA SMITH, MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:REBECCA SMITH, MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:NICOLE
Other - Last Name:JANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4084
Mailing Address - Country:US
Mailing Address - Phone:503-640-2757
Mailing Address - Fax:503-640-9753
Practice Address - Street 1:445 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4084
Practice Address - Country:US
Practice Address - Phone:503-640-2757
Practice Address - Fax:503-640-9753
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD171980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR185537OtherMEDICARE PTAN
OR500692184Medicaid