Healthcare Provider Details

I. General information

NPI: 1336280106
Provider Name (Legal Business Name): CINDY JEAN SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 NE HIGHWAY 20
CORVALLIS OR
97330-9695
US

IV. Provider business mailing address

3800 NW VAN BUREN AVE
CORVALLIS OR
97330-4954
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5915
  • Fax: 541-758-5916
Mailing address:
  • Phone: 541-754-1243
  • Fax: 541-754-5916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD 24409
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier226926
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: