1780677419 NPI number — CHRISTIE WALLSMITH M.D.

Table of content: CHRISTIE WALLSMITH M.D. (NPI 1780677419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780677419 NPI number — CHRISTIE WALLSMITH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLSMITH
Provider First Name:
CHRISTIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780677419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3808 N WILLIAMS AVE
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97227-1467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-970-2056
Provider Business Mailing Address Fax Number:
888-432-4730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3808 N WILLIAMS AVE
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227-1467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-970-2056
Provider Business Practice Location Address Fax Number:
888-432-4730
Provider Enumeration Date:
08/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  M1772 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: MD27140 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)