1043256779 NPI number — DR. WENDEL J SMITH M.D.

Table of content: DR. WENDEL J SMITH M.D. (NPI 1043256779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043256779 NPI number — DR. WENDEL J SMITH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
WENDEL
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1043256779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 17TH ST NW
Provider Second Line Business Mailing Address:
UNIT 307
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20009-2764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-669-6610
Provider Business Mailing Address Fax Number:
253-200-0907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 N 33RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98407-6420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-759-8500
Provider Business Practice Location Address Fax Number:
253-200-0907
Provider Enumeration Date:
06/21/2006

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: 208G00000X , with the licence number:  MD00036712 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0191192 . This is a "STATE L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8231649 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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