Healthcare Provider Details

I. General information

NPI: 1588157010
Provider Name (Legal Business Name): EVAN A SMITH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2018
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

IV. Provider business mailing address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-4900
  • Fax:
Mailing address:
  • Phone: 541-382-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD.0000902
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP222660
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: