Provider Demographics
NPI:1144269960
Name:SMITH, GARY A (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-1500
Mailing Address - Fax:360-397-3128
Practice Address - Street 1:2005 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4311
Practice Address - Country:US
Practice Address - Phone:360-397-4060
Practice Address - Fax:360-666-4772
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11631207P00000X
WAMD00046149207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8948203OtherL & I CRIME VICTIMS
OR026808Medicaid
WA0238840OtherL & I
WA8518334Medicaid
ORP00360925OtherRR MEDICARE
WAG8874475Medicare PIN
WA0238840OtherL & I