Healthcare Provider Details

I. General information

NPI: 1164519922
Provider Name (Legal Business Name): SUSAN E SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 EAST BARNETT RD
MEDFORD OR
97504-8301
US

IV. Provider business mailing address

PO BOX 4749
MEDFORD OR
97501-0227
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4673
  • Fax: 541-789-5678
Mailing address:
  • Phone: 970-385-7977
  • Fax: 970-385-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD38769
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number45611
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: